405800577-8-4-2022-29-AS-KBUY-CH5V6U-20220809161008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:10:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200923110447

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 43	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	03:33 PM
MET WITH:	Kirk Klotthor, Executive Director/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff are not properly supervising residents

INVESTIGATION FINDINGS:

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On 8/4/22022 at 11:05 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Administrator Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit.

On the allegation “Facility staff are not properly supervising residents,” the complainant’s concern was that there was an incident where two residents were “missing” in the building and it was not noticed until two Life Enrichment assistants looked for them for an activity. To investigate, LPA interviewed the administrator and staff.

On 9/25/20 at 2:59 pm, LPA interviewed the administrator. Administrator says there are 80 staff total and 3 caregivers in each neighborhood which has about 17 residents per neighborhood. He says each resident has a “call system” and that it is “obvious if they need attention.”
Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200923110447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 08/04/2022

NARRATIVE

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On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff #1 (S1) states they have never observed a situation where staff were not supervising residents. Staff #2 (S2) says staff are required to do “garden checks” explaining that staff are “to go to the garden and make sure residents are okay.” S2 says they have not observed staff “not checking on residents.” Staff #3 (S3) states that “some residents would go into other residents’ rooms. If a resident got lost, it was my job to go look for them.” S3 states that staff are required to do garden checks every 30-45 minutes, inspecting the garden areas to ensure residents are okay.

On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed two staff. Staff #4 (S4) says they do not know of any instances where staff were not supervising residents. Staff #5 (S5) states “Staff do garden checks once an hour or more frequent, if possible. I have never heard or knew of any staff who weren’t taking care of residents.” S5 explains that residents are allowed to walk around in the garden unsupervised.

Based on evidence obtained, the allegation “Facility staff are not properly supervising residents,” is deemed Unsubstantiated at this time. There is no evidence that staff are leaving residents unattended for lengthy periods of time nor that residents’ needs are not being met.

Exit interview conducted and the report emailed to the administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

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