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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 01/19/2023
Date Signed: 01/24/2023 09:30:02 AM

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
01/17/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230117110027
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: 52DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Erika Hampe, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Staff are not properly trained
Facility has insufficient staffing
INVESTIGATION FINDINGS:
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On 1/19/23 at 11:12 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint investigation visit to the facility listed above. LPA met with Erika Hampe, Administrator, and explained the purpose of the visit.

On the allegation, “Staff are not properly trained,” the complainant’s concern was that Erika Hampe, Administrator, and Staff #1 (S1) were giving medications to residents and they are not trained to do so. To investigate, LPA interviewed the administrator and residents and reviewed documentation.

On 1/19/23 at 11:20 am, LPA interviewed the administrator. The administrator states that she has medication training. Administrator states that on 1/11/23 she was handing out medications to residents and asked S1 to give medications to two residents on the AM shift. Administrator says she placed the medications in the envelopes, labeled them and gave them to S1 to distribute. Administrator says that S1 does not have medication training. Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 5
Control Number 29-AS-20230117110027
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: 01/19/2023
NARRATIVE
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On 1/19/23 between 3:04 pm and 3:45 pm, LPA interviewed residents. One resident states that the Executive Director Erika Hampe and S1 delivered medications to the resident.

On 1/19/23, LPA reviewed medication training for the administrator. Records indicate administrator shadowed staff on 11/11/22, however, the documentation does not specify the hours of training. Records do not appear to include the required training for facilities licensed to provide care to 16 or more persons.

Based on the evidence obtained, the allegation, “Staff are not properly trained,” is deemed Substantiated at this time. All employees who assist residents with self-administration of medication are required to have medication training.

On the allegation, “Facility has insufficient staffing,” the complainant’s concern was that there were no staff in the Wellness Department on 1/15/23 to assist residents with caregiving and medications. To investigate, LPA interviewed staff and residents and reviewed records.

On 1/19/23 between 11:20 am and 3:45 pm, LPA interviewed the administrator, staff and residents. The administrator and staff state that currently they are down two caregivers and one medication technician due to releasing these employees recently. Staff state that the shortage of caregivers and med-techs is making it challenging to get duties done and that typically they are staffed with one med-tech and two caregivers per shift. Residents interviewed state that medications have been delivered late on more than three occasions within the past two weeks. One resident says that there were no med-techs on one day this past week, that the Executive Director and S1 were delivering medications and that they were “very late.” Another resident says their evening medication was delivered so late that staff had to wake the resident.

On 1/19/23, LPA reviewed care staff assignments and found that there was one med-tech and one caregiver per shift on 1/15/23.

Based on evidence obtained, the allegation “Facility has insufficient staffing,” is deemed Substantiated at this time. Interviews and records review reveal that staff have been late in getting residents their medications on several occasions within the past two weeks.

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: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20230117110027
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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
HSC
1569.69(a)(1)
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1569.69(a)(1) Employees assisting residents with self-administration of medication; training requirements.
(a) Each residential care facility for the elderly...(1) In facilities licensed to provide care for 16 or more persons...This requirement was not met as evidenced by:
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Administrator will write a Statement of Understanding of the regulation cited above and write a commitment to ensure staff will not assist with medication management until they are fully trained. Administrator will provide the Statement and commitment to CCL by 1/20/23.
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Based on interviews and record review, the facility failed to ensure staff were properly trained on medication management prior to assisting residents with self-administration of medications which poses an immediate health and safety risk to residents in care.
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Type A
01/20/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This regulation was not met as evidenced by:
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Administrator will send a commitment to CCL by 1/12/23 stating she will send CCL a weekly staff schedule, an actual schedule of staff who worked the previous week, and reasons for staff not completing their shift(s).
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Based on interviews and records review, the licensee failed to ensure residents were assisted with medication management in a timely manner which poses an immediate health and safety risks 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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/17/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230117110027

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: 52DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Erika Hampe, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff are mishandling the residents’ medications.
INVESTIGATION FINDINGS:
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5
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7
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13
On 1/19/23 at 11:12 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint investigation visit to the facility listed above. LPA met with Erika Hampe, Administrator, and explained the purpose of the visit.

On the allegation, “Staff are mishandling the residents’ medications,” the complainant’s concern was that the administrator was left pills on the nurse’s desk because she couldn’t find the resident they belonged to.” To investigate, LPA interviewed the administrator and staff.

On 1/19/23, LPA spoke with the administrator. The administrator denies the allegation and says that she didn’t leave medications on the nurse’s desk. She says, “On Wednesday, 1/11/23 I was the only med tech that day, and Resident #1 (R1) takes a narcotic. I did not have it when I first passed out meds to R1 and returned within the hour to give R1 the narcotic.”
Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230117110027
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: 01/19/2023
NARRATIVE
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On 1/19/23 between 12:20 pm and 2:30 pm. LPA interviewed staff. Staff say they have no knowledge of administrator leaving pills on the nurse’s desk on or around 1/11/23.

Based on the evidence obtained, the allegation, “Staff are mishandling the resident’s medications,” is deemed Unsubstantiated at this time. There is no evidence at this time that suggests pills were improperly stored.

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

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5