405800577-8-11-2022-29-AS-KBUY-CHSMA4-20220830092537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:15:34 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-20200923102912

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: 45	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	10:24 AM
MET WITH:	Kirk Klotthor, Executive Director/Administrator		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Facility staff withheld water from residents

INVESTIGATION FINDINGS:

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On 8/11/22 at 10:24 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit.

On the allegation “Facility staff withheld water from residents,” the complainant’s concern was that there was a staff who was withholding water from residents because the staff did not want to change residents’ diapers. To investigate the allegation, LPA interviewed the administrator, staff, and family members of residents.

On 9/25/20 at 2:59 pm, LPA interviewed the administrator. Administrator explains that all three neighborhoods have filtered water at each kitchen in the neighborhood and residents are able to get water and food “pretty much.”

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: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 29-AS-20200923102912

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: 08/11/2022

NARRATIVE

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On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff, Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 says “this is not true. Residents are being given water.” S1 says they are a big advocate for abuse and they would report it. S2 says they are “not aware of this.” S3 says S3 heard about a staff withholding water from a resident, but didn’t observe it and didn’t know the staff person’s name nor resident’s name. S3 says “maybe water wasn’t pushed as much as it should be, but Wellness pushed me to give water to residents.” S3 reports that during meal times, some staff wanted to finish fast and push residents into the common areas. S3 says “Dementia residents don’t know they need water so it’s necessary to push residents to drink water. Some staff offered water, but didn’t push residents to drink.”

On 7/22/22 between 9:55 am and 10:45 am, LPA spoke with Staff #4 (S4) and Staff #5 (S5). S4 says there is “always water and cups on dining tables and we offer residents water every hour.” S4 says they don’t remember any staff refusing to give water to residents. S5 says they “feel water is more important than food.” S5 explains that “Residents need water at meals and in between” and that S5 ensures staff knows to offer residents water several times throughout the day, however, this is “not documented.” S5 describes that “residents need water, just like you and I like to have water several times throughout the day.” S5 says they do not know of any staff who withheld water from residents.

On 8/11/22 between 10:50 am and 1:22 pm, LPA spoke with Witness #1 (W1), Witness #2 (W2), Witness #3 (W3), and Witness #4 (W4). W1 says they have never seen staff withholding water from residents. However, W1 says that they “bring water bottles to mom, she drank a lot.” W1 reports that they made a complaint to Wellness that W1’s mother was not drinking an adequate amount of water. W1 says staff told W1 that “staff didn’t have a routine for when they offer residents water” and said they would try to give her mom more water. W1 explains that “Every time I offer my mother more water, she drinks it.” W1 says that W1’s mother was hospitalized recently and was found to have severe hydration. W1 says staff told W1 that they were “giving her food with higher water content.” W1 says they have checked twice since then and talked with two different staff, and Wellness gave W1 no indication as to how often they would be giving W1’s mother water. W1 requested that Wellness offers W1’s mother water hourly. W2 says they have not witnessed this and has ‘no complaints” against the facility. W2 says “They take very good care of my mother.” W3 says they “Have not experienced staff not giving residents water.” W3 says their sister is “never dehydrated and staff always give her enough water.” W3 says their impression is that staff are really honest and my sister is really well taken care of.” W4 says they have never experienced staff not giving water to residents. W4 explains “I believe it’s important to give water several times a day. When I visit, they (staff) always ask if we want something to drink.” Continued on 9099-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20200923102912

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: 08/11/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on the evidence obtained, the allegation “Facility staff withheld water from residents,” is deemed Unsubstantiated at this time. Interviews reveal that staff are offering residents an adequate amount of water. 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: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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