405850034-3-9-2023-29-AS-KBUY-CPX3EL-20230314181121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/09/2023
Date Signed: 03/09/2023 03:42:16 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
03/06/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230306082520

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	ERIKA HAMPE		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 51	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Karen Enciso, Interim Administrator		TIME COMPLETED:	04:06 PM

ALLEGATION(S):

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Facility staff were not present in the facility to assist residents in care

INVESTIGATION FINDINGS:

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On 3/9/23 at 12:35 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced initial complaint visit. LPA met with Karen Enciso, Interim Administrator, and explained the purpose of the visit.

On the allegation, “Facility staff were not present in the facility to assist residents in care,” the complainant’s concern was that there were no staff present in the facility. To investigate the allegation, LPA interviewed interim Administrator on 3/6/23, interviewed staff on 3/4/23 at 1:42pm, interviewed residents on 3/4/23 and 3/6/23, and interviewed witnesses on 3/6/23.

LPA determined from the investigation that in the early morning hours of 3/4/2023, there were no staff in the facility for over 5 hours. On 3/3/2023 and 3/4/2023, the designee in charge of the facility was the Residential Services Director/LVN, who was not present in the facility, but staff interviewed stated they were told to contact the Residential Services Director as the manager on duty if needed.
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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 4

Control Number 29-AS-20230306082520

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: 03/09/2023

NARRATIVE

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On 3/3/2023, the PM shift staff, 1 caregiver and 1 med tech, were scheduled to be off at 11:30pm. The NOC shift staff was supposed to consist of 1 caregiver and 1 med tech and start at 11:30pm. The NOC med tech called out sick for their shift and notified the Residential Services Director, who did not respond. The NOC med tech also notified the caregiver and med tech on the PM shift that they were not coming in. The NOC caregiver arrived to work around 11:00pm. The three staff working contacted the Residential Services Director/LVN regarding the staffing but did receive a response. The PM caregiver stayed past their shift, until 12:40am. The PM med tech stayed past their shift, until 12:40am. The NOC caregiver stated they were going to leave if they did not hear back from the Residential Services Director/LVN. At 12:55am, the NOC caregiver walked off their shift and left the facility without any staff. Based on information obtained during the investigation, the NOC caregiver walked off their shift because they were scared to work alone because they believed the facility was haunted.

The dining services staff started their shift at 5:50am. The first caregiving staff to show up on the AM shift was the AM med tech, who their 7am shift early at 6:46am on 3/4/2023. The facility was without any caregiving staff or med techs from 12:55am to 6:46am, a period of 5 hours and 51 minutes.

During the investigation, the LPA learned that one dining services staff is currently living on the facility property. Interim Administrator clarified that this staff could be approached by other facility staff if there was a situation and additional assistance was needed, but this staff does not provide any assistance unless other facility staff initiate it. Although this staff was on the premises during the absence of care staff on 3/4/2023, they were off-duty and did not provide any assistance or supervision to residents, as no staff informed them that assistance was needed.

During the time period where no care staff were present in the facility, at least one resident needed medication assistance with a PRN but did not receive it, and at least two residents stated they pushed their call button for toileting assistance but did not receive it.

Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, and the report and appeal rights given to the interim administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230306082520

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: 03/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/10/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Interim Administrator agreed to submit a schedule for March showing adequate staff coverage to CCL by 3/10/23. Interim Administrator agreed to train all staff about which managers should be contacted, if needed. Interim Administrator posted contact information in the Wellness Department, directing staff to call the Interim Administrator or Sr. VP of Operations, in case urgent issues arise.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above when no staff were present at the facility for 5 hours and 51 minutes, which posed an immediate health and safety 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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
03/06/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230306082520

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	ERIKA HAMPE		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 51	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Karen Enciso, Interim Administrator		TIME COMPLETED:	04:06 PM

ALLEGATION(S):

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Residents in care are not provided proper food service

INVESTIGATION FINDINGS:

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On 3/9/23 at 12:35 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced initial complaint visit. LPA met with Karen Enciso, Interim Administrator, and explained the purpose of the visit. On the allegation, “Residents in care are not provided proper food service,” the complainant’s concern was that the facility did not have adequate food, particularly perishable food. To investigate, LPA interviewed the Food Services Director, made observations, and reviewed records.

On 3/9/23 at 1:05 pm, LPA toured the kitchen and food storage areas and observed six gallons of milk and three tubs of fruit salad in the refrigerator, and a half full boxes of fresh bananas, oranges, and apples. LPA reviewed the list of residents’ dietary needs posted in the kitchen which did not state that any residents required dairy or extra dairy. LPA interviewed the Food Services Director who states that they order twice a week and have been ordering fruit salad instead of fresh melons as one third of the melons delivered had gone bad. LPA took photographs of the food for future reference.
Based on the evidence obtained, the allegation “Residents in care are not provided proper food service,” is deemed Unsubstantiated at this time.

Unsubstantiated

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4