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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 04:50:49 PM


Document Has Been Signed on 01/27/2023 04:50 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
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On 9/20/22, the facility self-reported an incident. The incident report states, “On 9/16/22 at approximately 10:00 am, Resident #1 (R1) was inadvertently given the wrong medication that was intended for another Resident #2 (R2). It was not until 12:00 pm, that the med-tech realized the error and then went to R1’s apartment and observed R1 sleeping. Med-tech woke up R1 and asked how R1 was feeling. R1 responded that R1 felt dizzy and tired.” On 1/26/23, LPA reviewed the incident report which indicates that emergency personnel were called and R1 had low blood pressure. The facility provided the wrong medication to R1 and failed to assist R1 with medication as prescribed by R1’s physician. Deficiency cited.

Exit interview conducted, deficiency cited, civil penalty issued, and report 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 04:50 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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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Administrator states an LVN has been hired since this occurred and administrator has confidence in her to prevent this from happening again. Administrator has contracted to have a nurse from Wilshire Home Health/Hospice of San Luis Obispo to provide a weekly medication training starting 2/3/23. Administrator will provide a copy of the sign-in sheet and send to CCL. Administrator will send CCL a commitment to ensure this training is conducted and the commitment will be sent to CCL by 1/30/23.
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Based on records review, the facility failed to assist resident with medication prescribed and instead, gave resident another resident’s medication which poses an immediate health and safety risk to resident 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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