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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:22:48 PM



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
02/16/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220216161019
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: 60DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Emily Villegas, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility does not provide transportation to residents for medical appointments.
INVESTIGATION FINDINGS:
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On 3/30/22 at 12:45 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced follow-up visit to deliver the final findings on the allegation listed above. LPA met with Executive Director Emily Villegas and explained the reason for the visit.

On the allegation “Facility does not provide transportation to residents for medical appointments,” the complainant’s concern was that the facility had further reduced the transportation services it provides to residents for medical appointments. The complainant stated that appointments are “now limited to four residents per day and only on Tuesdays and Thursdays.” To investigate the allegation, LPA interviewed the Executive Director Emily Villegas, former Business Office Manager Cathyann Paape and a credible Witness #1 (W1) and obtained documentation.

Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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-20220216161019
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: AVILA SENIOR LIVING AT DOWNTOWN SLO
FACILITY NUMBER: 405850034
VISIT DATE: 03/30/2022
NARRATIVE
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On 7/29/21 at 3:00 pm, LPA interviewed Business Office Manager (BOM), Cathyann Paape, regarding the allegation. BOM stated that the transportation hours had changed effective 5/25/21. She states that the prior to 5/25/21, the facility provided transportation to residents for medical appointments on Mondays and Wednesdays, 9:30 am – 3:30 pm and Fridays, 9:30 am – 12:00 pm. Further, she says that on 5/25/21 the days/hours changed to Tuesdays & Thursdays, 9:30 am – 3:00 pm. BOM said this was communicated to residents in a memo dated 5/25/21. LPA questioned why the days/hours were reduced for medical appointments, and BOM stated that they were “short-staffed.” The memo to residents dated 5/25/21 states “You are welcome to use our local Ride-On vans for transportation. The Concierge Desk can assist you with scheduling a pick up.”

In another memo dated 6/17/21 to residents, the facility re-iterates that transportation for medical appointments “are to be scheduled for Tuesdays and Thursdays only…If you have a medical appointment for any reason on a Monday, Wednesday, or Friday, it will be on an availability basis only and there is a charge of $35.”

The facility’s Plan of Operation under Transportation Program states: 1) Establish a regular bus route based on the needs and requests of the residents. 2) Make available a regular bus route Monday through Friday. This bus route may include (but is not limited to) stops at: Local Banks, Grocery Stores, Doctor’s Offices, Shopping Centers or Mall, and Senior Citizen’s Center. Additionally, the procedure listed for medical appointments states “Should the resident not have transportation, the community arranges for necessary transportation.” In the section Basic Services under Transportation, “The community will arrange and/or provide transportation to scheduled medical and dental appointments, shopping, dining and specified community events in a 25-mile radius. Transportation is available from 8 a.m. to 5 p.m. on designated days.”

In the facility’s admission agreement, it states “We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping and recreational facilities within a 12-mile radius. Transportation is available from 8:30 a.m. to 3:30 p.m., on designated days. Other transportation outside normal business hours may be arranged by the Resident with the Community’s Activities Director for an additional charge, or with an outside agency.

Continued on 9099-C.

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

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220216161019
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: AVILA SENIOR LIVING AT DOWNTOWN SLO
FACILITY NUMBER: 405850034
VISIT DATE: 03/30/2022
NARRATIVE
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On 10/21/2021 between 10:00 am and 3:00 pm, a credible Witness #1 (W1) spoke with five residents who stated that they have difficulty getting transportation services on the new restricted days. W1 states that residents attempt to schedule transportation with the facility at least a week in advance and the bus is already full. Residents are having to reschedule medical appointments they’ve had in place for months. W1 relays that residents have told W1 the facility does not arrange for other transportation.

On 3/14/22 at 11:38 am, LPA spoke with Resident #1 (R1). R1 states that R1 schedules her medical appointments, and then requests transportation with the facility. R1 states that on more than one occasion, R1 has not been able to get her transportation needs met. R1 says the facility offers another day, besides Tuesday or Thursday, and that she will be charged.

On 2/18/22 at 11:20 am, LPA interviewed Executive Director Emily Villegas who stated that the transportation hours for residents’ medical appointments had been reduced due to staffing shortages. She provided a copy of the “Ride Guidelines” which show that transportation for medical appointments can be scheduled for Tuesdays and Thursdays between 9:30 am and 3:00 pm, stating that “The latest (transportation) appointment should be scheduled so that the end time is no later than 3:00 pm.”

Based on the evidence obtained, the allegation “Facility did not arrange transportation for residents” is deemed Substantiated. The facility is not providing basic transportation services to residents in care.

Exit interview conducted, deficiencies cited, and a copy of report and appeal rights emailed to Administrator and Executive Director.

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

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220216161019
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: AVILA SENIOR LIVING AT DOWNTOWN SLO
FACILITY NUMBER: 405850034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
87465(a)(2)
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87465(a)(2) - Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...
The facility did not meet the requirements as evidenced by:
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Executive Director (ED) agreed to read, review and have a complete understanding of regulation 87465 and provide a signed statement of understating of requirements/regulation. ED commits to increasing transporation days and/or hours to meet residents’ needs. ED will send the signed statement and revised transportation schedule to CCL by 4/01/22. ED commits to discussing the transportation needs in a 4/6/22 town hall meeting.
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Based on staff, resident and witness interviews and documentation, the licensee did not comply with the above regulation, the facility did not aid with meeting residents’ medical needs and transportation which poses a potential 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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4