405850034-3-17-2023-29-AS-KBUY-CQCKZ3-20230328082004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:37:50 PM

Unsubstantiated

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
09/12/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220912111547

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	KAREN ENCISO		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 53	DATE:	03/17/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Karen Enciso, Interim Executive Director, and John Kuester, Maintenance Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mishandled a resident’s medication while in care

INVESTIGATION FINDINGS:

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On 3/17/23 at 10:50 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 9/12/22. LPA met with Karen Enciso, Interim Executive Director/Administrator by phone, and explained the purpose of the visit. In the Interim Executive Director’s absence in the facility, she appointed the John Kuester, Maintenance Director, as the point of contact.

On the allegation, “Staff mishandled a resident’s medication while in care,” the complainant’s concern was that the facility failed to assist a resident in refilling a prescription timely, resulting in the resident going without pain medication for 4-5 days over Labor Day weekend.

Continued on 9099-C.

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: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220912111547

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: 03/17/2023

NARRATIVE

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LPA reviewed medication documentation for Resident #1 (R1). Med techs at the facility requested R1’s doctor to refill the oxycodone PRN on 8/30/22, via phone call and voicemail, when there were 14 pills remaining. Med Techs faxed a refill request to R1’s doctor on 9/2/22 and called to follow up. R1’s doctor was out of the office until 9/7/22. The medication was refilled on 9/6/22 and R1’s medication was delivered 9/6/22 around 3:30pm by the pharmacy.

LPA interviewed med techs about their refill procedure. Med tech stated they usually fax the doctor for refills on R1’s Oxycodone PRN when there are 14 to 20 pills remaining. Med tech stated “sometimes the insurance won’t cover it until only a couple of pills are left.” Med tech stated the pharmacy, Pharmerica, tells the facility they cannot fill the prescription because insurance would not cover it. Med tech confirmed they had seen R1 go without their Oxycodone PRN for 2 to 3 days due to not being refilled over Labor Day Weekend.

LPA reviewed the Controlled Drug Record (CDR) for R1 for August 2022 for the Oxycodone PRN, dated 8/3/22. The CDR indicates the last Oxycodone PRN pill was given to R1 on 9/2/22 at 2300 hours. The next CDR does not have a legible date and all that can be seen is 9/_/22, and states the total amount received was 60 and total amount on the sheet was 60. The CDR starts on 9/6/22 with 60 pills, and the last pill was given on 9/22/22.

The investigation revealed that the facility requested R1’s Oxycodone PRN refill timely before they were out of pills, but due to R1’s doctor being on vacation and due to pharmacy and insurance issues, R1 went without their Oxycodone PRN from 9/3/22 until it was refilled and arrived at the facility in the afternoon of 9/6/22. It appears in this case the issues obtaining the refill were not due to facility staff’s actions. As a result, the allegation is deemed Unsubstantiated at this time. Technical Assistance is provided to the facility to ensure the facility has a procedure for when refills are not filled timely, including offering the resident the option to go to urgent care or an emergency room to obtain the medication.

Exit interview conducted and report given to the Maintenance Director.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC9099 (FAS) - (06/04)

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