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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 08/12/2021
Date Signed: 08/12/2021 06:05:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:CASSONDRA BRADFORDFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 51DATE:
08/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Suzanna Trompczynski, Administrator, and Emily Villegas, Resident Services DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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At 12:10 pm on 8/12/2021, Licensing Program Analyst (LPA) Chavez arrived at the facility to conduct a 10-day complaint visit on a separate complaint. LPA informed Administrator Suzanna Trompczynski and Residential Services Director (RSD) Emily Villegas the reason for the visit.

During record review and interviews, LPA determined that Staff #1 (S1) is not associated to the facility and is fingerprint cleared. At approximately 1:12 pm, LPA confirmed S1's identification. Administrator Trompczynski stated that S1 was not in the facility and scheduled to start at 3:00 pm today, 8/12/21. Administrator states S1 had been working in the facility since 7/04/21. Administrator stated she contacted S1 immediately and informed of the situation and asked S1 not to report to work until S1 is associated to the facility.

During record review and interviews, LPA determined that Staff #2 (S2) is not fingerprint cleared and is associated to the facility. At approximately 1:20 pm, LPA confirmed S1's identification. Administrator stated that S2 was in the facility working from 7:00 am to 3:00 pm today, 8/12/21 and that S2 had been working in the facility since 3/11/21. Administrator promptly spoke with S2, explained the situation, and asked S2 to leave the premises immediately. S2 left the facility and will return once S2 has obtained a criminal background clearance.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $1,000.00, $500 for each deficiency.

Exit interview conducted, and today's report and civil penalties were reviewed and emailed to Administrator. Appeal rights issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AVILA SENIOR LIVING AT DOWNTOWN SLO
FACILITY NUMBER: 405850034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2021
Section Cited

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87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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This requirement was not met as evidenced by interviews and record review. S1 has not obtained association with the facility. This poses an immediate health and safety risk to residents in care.
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Type A
08/13/2021
Section Cited

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87355(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department
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This requirement was not met as evidenced by interviews and record review. S2 has not
obtained a criminal background clearance. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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