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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:40:22 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
12/07/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20221207090158
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:
03/22/2023
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Karen Enciso, Interim Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are mismanaging residents’ medications
Staff speak inappropriately of resident while in care
Staff do not properly sanitize facility
INVESTIGATION FINDINGS:
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On 3/22/23 at 1:35 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings for the original complaint dated 12/07/2022. LPA met with Karen Enciso, Interim Executive Director/Administrator, and explained the purpose of the visit.

On the allegation, “Staff are mismanaging residents’ medications,” the complainant’s concern was that medication was not given as prescribed to Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3).

On 12/23/22, LPA interviewed Resident 1 (R1) about their medication. The resident stated on 12/4/22 they asked Staff 1, a Med Tech, for a PRN medication (Fioricet). Staff 1 (S1) returned with a medication, that R1 stated was Imodium, not Fioricet. S1 took the pill back and later returned with the requested Fioricet.

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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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 6
Control Number 29-AS-20221207090158
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: 03/22/2023
NARRATIVE
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LPA interviewed med techs about the use of the “pending pharmacy refill” note on the MAR. Med techs stated when med techs record medications not given as “pending pharmacy refill,” it is typically because the resident was out of the building and missed their medication, or the med tech mislabeled a missed medication. Residential services director stated that “pending pharmacy refill” notes likely indicated documentation issues on the med tech’s part.

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

On the allegation, “Staff speak inappropriately of resident while in care,” the complainant’s concern was that the kitchen staff spoke inappropriately of a resident by calling the resident a "belligerent alcoholic". On 12/13/22, Administrator Erika Hampe stated they had a staffing agency cook (Agency Staff 1) working on the dinner shift, between 4:30pm and 7:00pm from 11/26/22 and 12/5/22. Administrator stated they had performance issues with Agency Staff 1. Administrator stated in addition, a server in the kitchen notified her that on 12/2/22 the Agency Staff 1 referred to R1 as a “belligerent alcoholic.” Administrator stated they did not have Agency Staff 1 come back after 12/5/22. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation, “Staff do not properly sanitize facility,” the complainant’s concern was that the floor had not been cleaned or sanitized for two years. 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, a 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. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies issued on 9099-D and report and appeal rights 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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20221207090158
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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. 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: The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Administrator conducted training with all staff who are assisting residents with medications to ensure that residents get medications refilled and received on-time. Administrator sent CCL a Statement of Understanding of the regulation cited and proof the training was conducted on 3/6/23. POC cleared during visit.
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Based on record review and interviews, the licensee did not comply with the section cited above when medications were not given as prescribed for R1, R2, R3, which poses an immediate health and safety to persons in care.
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Type B
03/29/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Agency Staff 1 no longer works at the facility. Administrator agreed to discuss personal rights and mandated reporting with all staff and send written proof of the training by 3/29/23.

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Based on interviews, the licensee did not comply with the section cited above when Agency Staff 1 spoke inappropriately to R1 and violated their personal rights, which posed a potential 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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20221207090158
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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Administrator agreed to schedule carpet cleaning by March 31, 2023. Administrator agreed to send a copy of the invoice to LPA by April 15, 2023.
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Based on interviews and record review, the licensee did not comply with the section cited above when facility carpets were visibly stained, which posed a potential health, 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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
12/07/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20221207090158

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:
03/22/2023
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Karen Enciso, Interim Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff is not following resident’s dietary needs
INVESTIGATION FINDINGS:
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On 3/22/23 at 1:35 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings. LPA met with Karen Enciso, Interim Executive Director/Administrator, and explained the purpose of the visit.

On the allegation, “Staff is not following resident’s dietary needs,” the complainant’s concern was that staff were not following doctor's orders stating that R1 needs to be served double protein. LPA reviewed R1’s resident records and observed a physician’s order for double protein and vegetables . LPA observed a special list in the kitchen of residents with special diets. LPA observed R1 listed under the list of diabetic residents to ensure R1 receives more protein and carbs and less starches. LPA interviewed Food Services Director about R1’s dietary needs and they stated that they knew R1 is not diabetic and needs double protein and double vegetables, even though it is not listed in the kitchen.

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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20221207090158
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: 03/22/2023
NARRATIVE
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R1’s Resident Summary states that R1 needs double protein and double vegetables, can have any carbs and dessert they want. LPA interviewed R1 on 12/23/22, who stated that they did not want what was being served on the menu for dinner one day. R1 stated the staff offered alternate menu items, including chicken, a hamburger or a hot dog. R1 declined the chicken because they wanted fish instead, but fish was not available. R1 declined the hamburger because they had already eaten one the day before and declined the hot dog because R1 stated there was not enough protein in a hot dog. R1 stated they declined to eat that day. According to an interview with Administrator Hampe on 12/13/22 at 2:16pm, Hampe stated on 12/2/22, R1 asked Agency Staff 1 for fish for dinner, and Agency Staff 1 told R1 they did not know where the fish was. Agency Staff 1 also did not ask anyone where the fish was or call the Administrator to find out. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. LPA advised Administrator that all staff including temporary agency staff should be able to locate alternative meals or know to ask other staff, to try to accommodate resident’s dietary needs and preferences.

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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6