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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 05/04/2022
Date Signed: 05/04/2022 05:38:32 PM

Substantiated


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
11/02/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211102141401
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: 58DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Karen Enciso, Back-up Administrator and Operations SpecialistTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility is in disrepair / door is not working properly


INVESTIGATION FINDINGS:
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On 5/04/2022 at 10:45 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint visit with final findings to the facility listed above. LPA met with Karen Enciso, Back-up Administrator and Operations Specialist, and explained the purpose of the visit.

Regarding the allegation “Facility is in disrepair / door is not working properly,” the complainant was concerned that the pedestrian door from the facility into the garage was “very difficult to open and closes too fast for residents to get through with a walker.” The complainant stated that the facility “has not corrected this unsafe condition despite resident’s repeated requests.” To investigate the allegation, LPA interviewed the Executive Director, staff, and residents, and reviewed records.

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: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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 6
Control Number 29-AS-20211102141401
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: 05/04/2022
NARRATIVE
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On 11/05/21 at 10:15 am, LPA Chavez interviewed Executive Director Emily Villegas. Ms. Villegas stated that she is aware of Resident #1 (R1) having difficulty getting through the garage door from the garage to the facility. She said R1 approached her “a couple of times,” and that R1 told her that the door “swings open, needs an adjustment, it is not delaying long enough.”

On 11/05/21 at 10:30 am, LPA Chavez toured the pedestrian garage door with Executive Director. Staff #1 (S1) approached as we discussed the door. S1 stated that they have tried to come up with ways to fix the door so that it works for R1. S1 states that they have witnessed R1 push the door open and struggle to keep it open as R1 tries to get through it using a walker. LPA again spoke again with S1 on 5/04/22 at 11:50 am. S1 stated that “it is not a good door for the disabled.” S1 says they are aware of the concern has taken steps to fix the door.

On 11/08/21 at 1:42 pm, LPA interviewed R1. R1 explains that the door leading from the garage to the inside of the facility has about “50 pounds of pressure, immediate pressure” when opening. R1 states that R1 has to open the door “three times to get through it once.” R1 says they spoke about the door problems with Executive Director, Emily Villegas, “four to five times,” to the Maintenance Director, “three to four times,” and “twice” to the Business Office Manager.

On 4/23/22 between 12:54 pm and 1:35 pm, LPA spoke with three residents. Two residents stated that they have had situations where the garage door “was a challenge.” Specifically, Resident #2 (R2) described a situation where they held “the door for another resident using a walker.” R2 says the door is “self-closing and needing to be propped open for anyone with a walker or wheelchair, or if someone is moving something.” R2 said “it’s tough to get in” in those cases. R2 stated “it would be better if there were a hospital-type door there.”

Resident #3 (R3) said that R3 uses a wheelchair. R3 states that they have to prop the garage door open or use a cane to keep it open while entering the door. R3 describes the door as being “self-closing and “heavy, and challenging.” R3 relays a story that “a couple years ago, a friend told R3 about an incident where the friend “went through the door, got it open, and the resistance was so hard that the friend got knocked down by the door and banged up his skin.” R3 says the door is the same now as it was a couple years ago. R3 explains that “it would be difficult for residents not as strong as me.”

Continued on 9099-C.

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

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211102141401
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: 05/04/2022
NARRATIVE
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On 11/5/21 at 10:15 am, LPA toured the door entering into the garage from the facility. LPA tested the length that the door stays open for a person to pass through. LPA counted 10 seconds. On 11/09/21 at 1:10 pm, LPA reviewed an email and video the Executive Director. The ED states in the email that the garage door was adjusted recently to extend the delay. In the video, the ED opened the pedestrian garage door and let it close. LPA counted 18 seconds for the door to close.

On 4/29/22 at 2:35 pm, LPA reviewed the facility’s maintenance request forms. On 11/30/21, a maintenance request was submitted to “delay door please” for the garage door.” On 5/04/22, LPA spoke with S1 who stated the door was adjusted to close more quickly in order for it to close entirely and lock into place. At 4:14 pm, LPA and Back-up administrator tested the door which closed within 18 seconds.

Based on the evidence obtained, the allegation “Facility is in disrepair / door is not working properly” is deemed Substantiated at this time. The facility’s garage is used by residents with disabilities and does not have a door that accommodates their ability to navigate through it safely. The facility was aware of the problem and the problem continues to exist.

Exit interview conducted, deficiencies cited, and a copy of the report and appeal rights emailed to the back-up administrator.

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

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20211102141401
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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The facility did not meet the requirements as evidenced by:
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Administrator has committed to ensure the garage’s pedestrian door delays a sufficient amount of time for disabled residents to enter/exit. Administrator has committed to having conversations with residents who use the garage and ensure they have no difficulties with the pedestrian door by 5/11/22. Administrator will send CCL a copy of resident names and dates conversations took place.
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Based on staff and resident interviews and records review, the licensee did not comply with the regulation. The facility did not provide a safe passage way for residents with disabilities.
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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: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/02/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211102141401

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: 58DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Karen Enciso, Back-up AdministratorTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Resident sustained an injury while in care
INVESTIGATION FINDINGS:
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On the allegation “Resident sustained an injury while in care,” the complainant’s concern was that R1 sustained injuries while trying to enter the garage’s pedestrian door.” The complainant states that R1 had cuts on R1’s arm due to the pedestrian door hitting R1 when trying to enter. The complainant adds that R1 uses a walker. To investigate the allegation, LPA interviewed the Executive Director, staff, and residents, and reviewed records.

On 11/05/21 at 10:15 am, LPA interviewed the Executive Director. Ms. Villegas states that she is aware of R1 having difficulty getting through the garage door from the garage to the facility. However, she says she was unaware of any injuries to R1 or any other resident. On 11/05/21 at 10:30 am, LPA Chavez spoke with the S1 who says that R1 informed S1 of R1’s injuries, however, S1 states they did not witness R1 obtaining the injuries.

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

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211102141401
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: 05/04/2022
NARRATIVE
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On 11/08/21 at 1:42 pm, LPA spoke with R1. R1 describes that they have “gashes on my arm from the door handle hitting my arm.” R1 continues that they have a “dozen scrapes on my hand and arms from the door.”

On 4/23/22 between 12:54 pm and 1:35 pm, LPA spoke with three residents. R3 says that R3 has not had injuries from the pedestrian door in the garage, however, R3 relays that they had a friend who told R3 about injuries they incurred a couple years ago when going through the pedestrian garage door.

On 5/04/22 at 3:00 pm, LPA reviewed resident records for August 2021 through November 2021. Wellness charting reveals that R1 had not requested services from Wellness during this period, and there were no incident reports on record.

Based on evidence obtained, the allegation “Resident sustained an injury while in care,” is deemed Unsubstantiated at this time. There were no witnesses to the injuries and records indicate that R1 was not treated for the alleged injuries.



Exit interview conducted and a copy of the report emailed to the back-up administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6