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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/01/2023
Date Signed: 03/01/2023 02:03:22 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
12/27/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20221227090223
FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:KAREN ENCISOFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 51DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cindy Morris, Interim Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff failed to administer residents' medication as prescribed
INVESTIGATION FINDINGS:
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On 3/1/23 at 10:45 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint investigation visit to deliver final findings on an original complaint dated 12/27/22. LPA met with Cindy Morris, Interim Executive Director, and explained the purpose of the visit.

On the allegation, “Staff failed to administer residents’ medication as prescribed,” the complainant reports that during the holidays, the facility was short staffed and residents did not get their medications or didn’t receive them in a timely manner.

LPA interviewed Resident #1 (R1) about R1’s medications. R1 says there were no med-techs on duty on 12/25/22 and 12/26/22 in the AM shift and that R1 received their medication late. R1 says that on 12/27/22, there were no med-techs, and that the executive director was dispensing medications and AM meds didn’t get passed until late AM or afternoon. LPA reviewed the MARs for R1 for December 2022 and noted that R1 did not receive Meclizine on 12/25/22 and 12/26/22. 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: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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-20221227090223
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: 03/01/2023
NARRATIVE
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LPA interviewed Resident #2 (R2) about R2’s medication. A Med Tech provided R2 their medication, and R2 noticed their Escitalopram was not in the pill cup. R2 asked about the Escitalopram and the Med Tech said they ran out of refills. R2 stated they had refills on the medication and did not understand how they could run out of it. LPA reviewed R2’s MARs for December 2022 and noted that R2 did not receive Escitalopram on 12/23/22 and 12/24/22.

LPA interviewed Lindsay Dykstra, LVN/Residential Services Director, who says that on 12/25/22, she and the executive director Erika Hampe were providing medications to residents on the AM shift as staff had called out. LVN states that Resident #3 (R3) was not given Adderall on 12/26/22 as prescribed and says “the med-tech missed giving that medication on 12/26.” LPA reviewed R3’s MAR and observed on 12/26/22 and 12/27/22 one of the three acetaminophen doses (1pm) was not given; on 12/26/22 and 12/27/22 their calcium acetate for 1pm was not given. LPA did not observe Adderall for R3 on R3’s MAR and did not observe any doctor’s orders for the medication. Based on interviews and record review, the allegation, “Staff failed to administer residents’ medication as prescribed,” is deemed Substantiated at this time.”

Exit interview conducted, deficiency cited, and the report and appeal rights given to the Interim Executive Director.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20221227090223
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will create a weekly sign-up sheet for staff willing to work overtime, and supplement call outs with staffing agencies. Licensee will conduct training with all staff who are assisting residents with medications to ensure that residents get medications refilled and received on-time. Licensee will send CCL a Statement of Understanding of the regulation cited and a commitment by 3/2/23 stating the training will be conducted by 3/6/23.
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Based on interviews and record review, the licensee did not comply with the section cited above in that staff failed to deliver medications to R1 and R2 or delivered them late which poses an immediate health, safety or personal rights risk to persons 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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
12/27/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20221227090223

FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:KAREN ENCISOFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 51DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cindy Morris, Interim Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff failed to provide adequate food service
INVESTIGATION FINDINGS:
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On 3/1/23 at 10:45 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint investigation visit to deliver final findings on an original complaint dated 12/27/22. LPA met with Cindy Morris, Interim Executive Director, and explained the purpose of the visit.

On the allegation, “Staff failed to provide adequate food service,” the complainant reports that between 12/24/22 and 12/26/22, the facility did not have bottled water, milk, bacon, fruit, bread or sausage, on 12/25/22, residents were served a hamburger that was overcooked with a stale bun, and on 12/26/22, residents were only given a sandwich and a small bag of chips. LPA reviewed menus for 12/25/22 which indicated split-pea soup for lunch, pulled pork sandwiches with mac and cheese, coleslaw, and cheesecake. The menu for dinner 12/25/22 indicates split-pea soup, honey BBQ chicken with mac and cheese, dill carrots with banana cream pie. Another menu LPA reviewed indicates lunch on 12/25/22 was roasted corn chowder, corned beef and cabbage, with boiled potatoes and frosted marble cake. Dinner for 12/25/22 was roasted corn chowder, country fried steak with mashed potatoes and country gravy, dilled carrots and frosted marble cake. 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: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 5
Control Number 29-AS-20221227090223
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: 03/01/2023
NARRATIVE
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One of the menus indicates dinner on 12/26/22 was Caesar salad, pork schnitzel with parmesan risotto and seasoned broccoli and poppyseed cake. LPA interviewed Food Services Director (FSD) on 12/28/22, who indicated on 12/26/22 tilapia was on the menu but stated they had to serve salmon instead. However, the menu does not indicate tilapia or salmon for that day. The interview indicated FSD did not believe the facility was out of any food and beverage items that week, but he was not at the facility some of the days. LPA interviewed residents on 1/27/23, and interviews revealed the facility was out of ice cream for about a week. LPA observed food services on 1/27/23 and observed fish and chips and BLT sandwiches and optional desserts. LPA observed the meals to be adequate. In an interview with FSD, it was confirmed residents can ask for additional portions of food and can ask for items on the alternate menu. LPA also observed an adequate amount of perishable and non-perishable food in the kitchen and food storage. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. However, LPA recommends the facility follow the menu it publishes to residents as closely as possible; orders food timely so that the weekly menu can be followed; takes regular inventory to ensure unique dietary foods are ordered timely (lactose-free ice cream, sugar-free items, etc); and recommends Food Services Director provides cooks additional training to ensure menus are followed and the food is appetizing to residents.

Exit interview conducted and report given to Interim Executive Director.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5