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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 02:00:10 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
01/19/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230119084557
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: 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 are not following proper food handling and storage.
Staff mishandle the residents’ medications.
Staff are not following infection control procedures.
Staff do not properly maintain the facility.
INVESTIGATION FINDINGS:
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On 3/1/23 at 10:45 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 1/19/23. LPA met with Cindy Morris, Interim Executive Director, and explained the purpose of the visit.

On the allegation, “Staff are not following proper food handling and storage,” the complainant’s concern was that staff are not properly storing food which can contaminate the food.

On 1/12/23, a credible witness observed a large container of white ice cream and another large container of brown ice cream in the freezer without lids, an open package of tortillas whose edges were curling and cracked in the refrigerator, and two uncovered pieces of cooked chicken on a tray in the pantry.

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-20230119084557
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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On 1/27/23, 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 allegation is deemed Substantiated at this time. The facility failed to properly store food items.

On the allegation, “Staff mishandle the residents’ medications,” the complainant’s concern was that staff were not obtaining medication refills on-time and residents did not receive their medications.

On 2/3/23, LPA interviewed Resident #1 (R1). R1 says that in mid-January, they did not receive their thyroid medication two days in a row. R1 says on the first day, staff came to R1’s room and assisted R1 with their medication but did not provide R1 their thyroid medication. R1 says they blew it off and on the second day, R1 says when staff arrived with R1’s morning medication, the thyroid medication was missing and staff could not tell R1 the reason. R1 says they went to Wellness and received it from another staff.

On 2/8/23, LPA reviewed the MARS for R1 with administrator and LVN. ED and LVN could not explain the reasons why the MARS showed R1 did not receive her Escitalopram 10MG 2x daily in the morning on 1/15/23 and 1/21/23. There were no staff notes showing a reason why the resident did not receive the medication on those dates.

On 2/21/23, LPA reviewed Medication Administration Records (MARs) for January 2023 which indicate that R1 did not receive their thyroid medication as prescribed. MARS shows this daily medication was not given on 1/8/23 and 1/9/23 and there were no staff notes giving a reason the medication was not provided to the resident.

On 1/19/23 a 2:14 pm, LPA interviewed the lead med-tech. Lead med-tech states that R1 came to the Wellness Department on or around 1/11/23 saying that the med-tech did not bring R1 their morning medications. The med-tech apologized and gave R1 their medication. Lead med-tech also confirms that on 12/25/22, there were no med-techs in the morning and that the administrator arrived around 10:00 am and began dispensing medications.

Based on interviews and record review, the allegation, “Staff mishandle the residents’ medications,” is deemed Substantiated at this time. Documentation and interviews show that residents are not receiving medications as prescribed.

Continued on 9099-C.

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-20230119084557
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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On the allegation, “Staff are not following infection control procedures,” the complainant states concern that staff are not informing residents and visitors of a recent outbreak of COVID-19 and that staff are not wearing N95 masks during the outbreak. On 1/12/23, a witness entered the facility and states there was no signage indicating positive cases of COVID-19 and staff were not wearing N95 respirators.

On 1/19/23 at 11:12 am, LPA visited the facility to investigate a separate complaint. During the investigation, LPA learned that two staff had tested positive for COVID-19 on 1/11/23, 1/12/23 and 1/14/23. At the time of LPA’s visit, the two residents had not cleared isolation, having tested positive on 1/7/23, and 1/10/23. LPA witnessed more than five staff wearing surgical masks and no other staff wearing N95 masks. LPA observed that the facility did not have signage at the central entry point indicating cases of COVID-19 in the facility.

On August 19, 2021, PIN 21-38-ASC stated RCFEs must follow current CDPH masking guidance, which required all staff to wear a mask. In addition, the PIN also states “facilities must also continue to adhere to Cal/OSHA’s standards for Aerosol Transmissible Diseases (ATD) pursuant to Title 8 of the California Code of Regulations, which requires respirator use in areas where suspected and confirmed COVID-19 cases may be present…Masking requirements for N95 respirator…also apply to temporary and contracted facility staff.” Based on the information provided in the PIN, an N95 respirator should have been worn by all staff in areas with suspected or confirmed COVID-19 cases and therefore, the allegation, “Staff are not following infection control procedures,” is deemed Substantiated at this time.

On the allegation, “Staff do not properly maintain the facility,” the complainant was concerned that the facility carpet was dirty in several places. On 1/3/23, LPA toured the facility and observed stained carpeting in the hall near the Wellness Department, at the entrance inside room 214, inside room 223, inside the entrance of room 357, and on the external walkway near room 221. On 1/12/23, the witness observed dirty carpets in three resident rooms and provided photos (220, 103, 263).

On 12/23/22 at 10:42 am, a resident reports that they have slipped on the dirty, worn carpet in their room twice in the past week. Resident states that the carpet has not been cleaned in at least two years and is concerned because their admission agreement states the carpets are to be cleaned annually. On 12/13/22 at 2:16 pm, LPA interviewed Erika Hampe, Executive Director (ED). ED states that the carpets in resident rooms are shampooed annually and she is uncertain how frequently the carpets in common areas are cleaned. Based on observations and interviews, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies 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: 3 of 5
Control Number 29-AS-20230119084557
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
87555(a)(9)
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87555(a)(9) General Food Service Requirements (a)(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
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Administrator immediately covered the items in the refrigerator, freezer, and pantry. Licensee will counsel the Food Services Director (FSD) on proper food handling procedures. If the FSD has been counseled prior, this discussion will be escalated. Licensee will provide a copy of the signed/dated counseling letter to CCL by 3/2/23. Training on proper food handling will be completed with kitchen and dining staff by 3/6/23 and a commitment stating as such to CCL by 3/2/23.
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Based on observations, the licensee did not comply with the section cited above by having uncovered food items in the freezer, refrigerator and pantry which poses an immediate health and safety risk to residents in care.
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Type A
03/02/2023
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care, (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:

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LVN/Residential Services Director will assess procedures for medication refills and provide greater direction and accountability for ensuring refills are completed so that residents do not miss medications. This assessment and training will be completed by 3/6/23, and a commitment will be sent to CCL by 3/2/23 stating this will be completed.
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Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring R1’s refills were ordered in time and not providing resident with medication 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: 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: 4 of 5
Control Number 29-AS-20230119084557
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
87468.1(a)
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87468.1(a) Personal Rights of Residents in All Facilities, 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 requirement was not met as evidenced by:
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Upon advice from LPA, Administrator immediately gave N95 masks to all staff and instructed them to wear them. Administrator will ensure proper infection control signage upon entry of facility. No further action is required at this time.
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Based on observations, the licensee did not comply with the regulation cited above by not ensuring staff were wearing at minimum N95 respirators while residents were isolating for COVID-19.
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Type B
03/08/2023
Section Cited
CCR
87468.1(b)(2)
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87468.1(b)(2) Personal Rights of Residents in All Facilities, 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 requirement was not met as evidenced by:
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Administrator conferred with the Maintenance Director and provided a schedule of carpet cleaning scheule by a vendor with all resident rooms containing carpeting to be industrial cleaned by the end of February 2023. A list of common areas that were or will be cleaned will be sent to CCL by 3/2/23. A commitment that this has been completed will be sent to CCL by 3/2/23.
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Based on observations and interviews, the licensee did not comply with the section cited above as there were several areas throughout the facility with stained carpeting which poses a potential health and safety and personal rights 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: 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: 5 of 5