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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 01/03/2023
Date Signed: 01/03/2023 05:57:26 PM


Document Has Been Signed on 01/03/2023 05:57 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:ERIKA HAMPEFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 57DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Erika Hampe, Administrator, Lindsay Dykstra, LVN/Residential Services DirectorTIME COMPLETED:
06:10 PM
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On 1/03/23 at 11:02 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Lindsay Dykstra, LVN/Residential Services Director, and explained the purpose of the visit. At 11:120 am, Erika Hampe, Administrator, arrived and LPA informed of the reason for the visit.

LPA toured the facility with Administrator, Residential Services Director, and Maintenance Director and observed the following: The facility is missing infection control signage at the front entrance and throughout the facility on handwashing, cough etiquette and use of masks with the exception of the first floor restrooms which had signs posted for handwashing. Licensee will post the visitor policy at the front door and infection control signage throughout the facility. The facility has soap and paper towels in common area bathrooms (4). Fire extinguishers (13) are located throughout the facility. The extinguishers are fully charged and were inspected on 1/24/22 with the exception of two extinguishers on the second and third floors which were not marked showing they were inspected. Licensee will consult with the fire company to determine their inspection dates, if any, and send documentation to LPA by 1/05/23.

At 12:03 pm, LPA observed a round, wooden table approximately five feet in diameter leaning against the stairwell in the first floor southeast entrance/exit area going toward the fire exit door. The table’s feet stuck out approximately three feet into the walkway obstructing the fire exit which violates the facility’s fire clearance. Deficiency cited.

At 1:20 pm and 3:40 pm, LPA observed Staff #1 (S1) and Staff #2 (S2) respectively wearing their masks under their chins. 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. Deficiency cited.

Continued on 809-C.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
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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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
VISIT DATE: 01/03/2023
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At 1:25 pm, LPA toured the kitchen and observed an uncovered 3-gallon container of ice cream in the freezer, a container of strawberries with mold on them, three cucumbers with mold on them, and a torn bag of tortillas going bad in the refrigerator. This violates food storage requirements as food items were not stored properly and not discarded prior to going rancid. Deficiency cited.

At 1:35 pm, LPA conducted the Infection Control mitigation module with the administrator.



Exit interview conducted, deficiencies cited, and the report and appeal rights emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/03/2023 05:57 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: 01/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1
Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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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. This is a Repeat Violation of this regulation, and therefore, the facility is incurring a $250 civil penalty.
POC Due Date: 01/04/2023
Plan of Correction
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When LPA approached staff, they immediately place face covering on properly. Administrator will provide a written committment to CCLD by 1/4/23, stating that she will train all staff on the proper use of face coverings in the "safety topic of the month" training. Administrator commits to completing the training by 1/18/23. Administrator states she will be giving S1 and S2 a written warning and will send CCL the written, signed documents by 1/4/23.
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the facility failed to keep a fire exit clear of obstruction which poses an immediate health, safety and personal rights risk to residents in care. This deficiency incurs an immediate civil penalty of $500.
POC Due Date: 01/04/2023
Plan of Correction
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Administrator immediately removed the item and eliminated the obstruction. Administrator has had a conversation with the Maintenance Director and will document this conversation and both parties will sign and date, then administrator will send document to CCL by 1/4/23.
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: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/03/2023 05:57 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: 01/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555
87555-General Food Service Requirements, (b)...(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the above regulation. Food items were not stored properly and not discarded prior to going rancid which poses an immediate health and safety risk to residents in care. This is a Repeat Violation of this regulation, and therefore, the facility is incurring a $250 civil penalty.
POC Due Date: 01/04/2023
Plan of Correction
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Administrator immediately removed the rancide food items. Administrator will send CCL a written committment stating that she will inspect the expectation daily starting today until she has a confidence that the Food Services Director is inspecting the food so that nothing goes bad.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4