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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:44:41 PM


Document Has Been Signed on 03/23/2022 04:44 PM - It Cannot Be Edited

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: 59DATE:
03/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Emily Villegas, Executive DirectorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Chavez conducted an unannounced Case Management visit to follow-up on an incident that was reported by the facility. LPA met with Emily Villegas, Executive Director, and explained the purpose of the visit.

On 3/14/2022, the facility sent CCLD an incident report stating that Resident #1 (R1) had obtained an injury while assisted by staff. Specifically, it states Staff #1 (S1) “went to answer R1’s page to come down for a sandwich and head back to her room. While coming down the ramp the wheelchair tire got caught on R1’s left foot. S1 tried to reach over to prevent R1 from falling, but resident went forward landing on R1’s knees. R1 landed knees first then hit R1’s face on the floor. 911 was called by staff to take R1 to the hospital.”

On 3/23/2022, LPA reviewed hospital discharge instructions for R1. R1 visited the hospital on 3/12/2022. Hospital instructions state that R1 sustained “Nasal bone fractures, fracture of finger of right hand, and fracture of maxilla.” On 3/23/2022 at 2:12 pm, LPA interviewed Staff #2 (S2) who confirmed that R1 had a “nasal fracture, right finger fracture, and maxilla fracture from falling from the wheelchair that day.” Since R1 sustained injuries while in the care and supervision of staff, the facility is being cited for failure to provide competent supervision.

A $1,000 immediate civil penalty is assessed today for injury to R1. The Executive Director was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f).



Exit interview conducted, deficiency cited on 9099-D, civil penalty issued, appeal rights issued, and a copy of this report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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Document Has Been Signed on 03/23/2022 04:44 PM - It Cannot Be Edited

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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
Section Cited

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87468.2(a)(4) Personal Rights. Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Based on documentation and an interview, S1 was not qualified to assist R1 which caused R1 to fall face forward on the floor sustaining a right nasal bone fracture, fracture of finger of right hand, and fracture of maxilla which posed 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: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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