405850034-6-7-2022-29-AS-KBUY-CFDPCP-20220614111216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:36:04 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
06/06/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220606150012

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	KAREN L ENCISO		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 58	DATE:	06/07/2022
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Kari Bowron, Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff is not following COVID-19 protocols.

INVESTIGATION FINDINGS:

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On 6/07/2022 at 2:10 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-Day Complaint visit to the facility above. LPA met with Kari Bowron, Executive Director, and explained the purpose of the visit.

On the allegation “Facility staff is not following COVID-19 protocols,” the complainant’s concern was that Staff #1 (S1) was interacting with a resident in the dining room wearing a face covering improperly, below the nose and mouth. To investigate the allegation, LPA interviewed a credible witness and the administrator.

On 6/02/22 at approximately 4:15 pm, a credible Witness #1 (W1) observed S1 “standing by the counter in the dining room talking with a resident who stood about three feet away.” W1 stated that S1’s mask was below their nose and mouth, they were not eating or drinking, and they were leaning on the counter “looking like they had been there awhile.”
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: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220606150012

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: 06/07/2022

NARRATIVE

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On 6/07/22 at 2:20 pm, Executive Director states that she observed S1 today with their mask not worn properly and had a conversation with them and their supervisor.

Based on the evidence obtained, the allegation “Facility is not following COVID-19 protocols,” is Substantiated at this time. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.

Exit interview conducted, deficiency cited, civil penalty issued, and a copy of this report and appeal rights emailed to Administrator and Executive Director.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220606150012

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: 06/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/08/2022 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director (ED) has committed to giving S1 a final written warning. Infectious control training will be held with staff, and ED will emphasize the reasons for proper use of PPE for residents and staff. A staff sign-in sheet from the training with staff printed names, signatures, and date of training will be sent to LPA by 6/08/22. ED will address the mask issue with the Dining Services Director, document the conversation, and send to LPA by 6/08/22. .
	8 9 10 11 12 13 14	Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights 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: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

LIC9099 (FAS) - (06/04)

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