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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:31:48 PM


Document Has Been Signed on 05/10/2022 04:31 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:KAREN L ENCISOFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 60DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:44 PM
MET WITH:Karen Enciso, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 5/10/2022 at 3:45 pm, Licensing Program Analyst (LPA) Chavez arrived at the facility to conduct an unannounced case management visit. LPA informed Administrator Karen Enciso the reason for the visit.

During interview and record review, LPA determined that Staff #1 (S1) and Staff #2 (S2) were not associated to the facility when working in the community. On 5/09/22 at 2:56 pm, LPA confirmed S1's and S2’s identifications.

On 5/11/2021 at 9:02 am, Ms. Bradford stated in an email to LPA that S1 was the designated administrator on 5/18/21 and 5/19/21. On 5/09/22 at 2:53 pm, LPA performed a search in Guardian for S1, and S1 was not in Guardian and therefore not associated with the facility. On 7/06/21 at 4:09 pm, Former Business Office Manager Cathyann Paape emailed LPA to inform that Staff #2 (S2) was the administrator on record for the week of 6/06/21 to 6/12/21. On 5/09/22 at 3:10 pm, LPA searched in Guardian for S2. S2 was associated to the facility, however S2 was not associated until 7/06/21, after the dates S2 worked in the community. On 5/10/22, LPA interviewed the administrator who confirmed that S2 worked 6/07/21 through 6/11/21.

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, civil penalties, and appeal rights emailed to Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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 05/10/2022 04:31 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: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2022
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 interview and record review. S1 and S1 had not obtained association with the facility during their time working in the facility. 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: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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