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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 01/27/2023
Date Signed: 01/27/2023 04:54:47 PM


Document Has Been Signed on 01/27/2023 04:54 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: 53DATE:
01/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Erika Hampe, AdministratorTIME COMPLETED:
05:10 PM
NARRATIVE
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On 1/27/23 at 11:42 am, LPA visited the facility to continue a complaint investigation. During the visit, LPA visited with residents who stated that they had requested ice cream, and staff said there was none. At 12:46 pm, LPA toured the kitchen and observed a three-gallon container of ice cream uncovered in the freezer and a bowl with salad uncovered in the refrigerator. Based on observations, the facility failed to properly store food items.

Exit interview conducted, deficiency cited, civil penalty issued, and the report 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/27/2023 04:54 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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2023
Section Cited

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87555(b)(9)-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. The facility did not meet the requirements as evidenced by:
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On 1/11/23, Administrator committed to audit the refrigerators and freezers daily. Today, the administrator has committed to writing-up the Food Services Director and send write-up to CCL by 1/30/23. Administrator will create a daily inspection log for the refrigerators and freezers and send a copy to CCLD by 1/30/23 and upon request.
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Based on observations, the licensee did not comply with the above regulation. Food items were not stored properly which 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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