405850034-5-6-2022-29-AS-KBUY-CEDQPY-20220513122130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 05/06/2022
Date Signed: 05/06/2022 04:43:59 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
10/18/2021 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20211018141400

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	CASSONDRA BRADFORD		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 60	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	01:42 PM
MET WITH:	Kaylene Duvall, Business Office Manager		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff failed to assist residents in self-administration of medication

INVESTIGATION FINDINGS:

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On 5/06/2022 at 1:42 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint visit with final findings to the facility listed above. LPA met with Kaylene Duvall, Business Office Manager, and explained the purpose of the visit.

Regarding the allegation “Staff failed to assist residents in self-administration of medication,” the complainant stated that “residents reported that they received their medications hours late or not at all on 10/10/21.” The complainant clarifies this took place “on the night shift.” 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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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 3

Control Number 29-AS-20211018141400

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: 05/06/2022

NARRATIVE

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On 10/22/21 at 11:45 am, LPA interviewed Emily Villegas, Executive Director. Ms. Villegas stated that “it was the first day that the new med-tech, Staff #1 (S1) was working on their own.” Ms. Villegas said that S1 “began passing out meds at 9:00 pm and got most residents their meds between 9:00 pm and 10:00 pm, however, three residents received their meds after 10:00 pm. S1 had to wake some of them to take their meds including Resident #1 (R1) and Resident #2 (R2).” She continues that the residents “weren’t happy about being waken and receiving their meds late.”

On 5/6/22 between 2:08 pm and 2:53 pm, LPA interviewed Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4). R1 stated there was “one time I didn’t get my evening medications.” R1 says they went to bed, and the med-tech that typically delivers medications went home. R1 says that R1 pushed their alert button, and Staff #2 (S2) arrived between 11:00 pm and 11:30 pm to deliver meds. R1 states that they were already asleep and did not answer the door when S2 arrived and did not get their medications that evening. R2 states that they “always get my meds, didn’t miss any.” R3 states that “there has never been a time when I didn’t get my medications.” R4 explains that there was “one night when I got my medications late.” R4 further states that staff was supposed to bring R4’s meds at 10:30 pm and they did not. R4 pushed their alert button and requested the medications and says that the med-tech arrived between 11:00 pm and 11:30 pm.

Based on evidence obtained, the allegation “Staff failed to assist residents in self-administration of medication,” is deemed Substantiated at this time. Staff did not provide medications or did not provide medications on-time to three residents.

Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211018141400

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: 05/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care, (4) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	The licensee will train medication technicians on proper self-administration of medications and review regulation 87465. Licensee will provide a training sign-in sheet to CCL by 5/13/22.
	8 9 10 11 12 13 14	Based on staff and resident interviews, the licensee did not comply with the regulation. The licensee did not ensure residents were provided medications as prescribed. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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