405850034-3-9-2023-29-AS-KBUY-CR7LJ3-20230424084711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/09/2023
Date Signed: 03/09/2023 03:57:06 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
01/03/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230103092831

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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Staff not providing adequate 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 follow-up visit to deliver final findings on the original complaint dated 1/3/2023. LPA met with Karen Enciso, Interim Administrator, and explained the purpose of the visit.

On the allegation, “Staff not providing adequate food service.(Staff is not following resident’s dietary needs),” the complainant’s concern was that staff were not following doctor's orders regarding special diets. LPA reviewed Resident #1’s (R1) resident records and observed a physician’s order dated 11/10/22. R1’s Resident Summary, received by CCL on 12/19/2021, states that R1 needs double protein and double vegetables, can have any carbs and dessert they want, and that they are allergic to pepper and bell pepper.

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)

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Control Number 29-AS-20230103092831

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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LPA observed a Dietary Needs 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, but it does not list R1 as having any allergies. LPA interviewed R1, who indicated at one meal they ordered fish and were given a piece of fish with Cajun seasoning on it (which contained pepper), and R1 stated they could not eat it because of the pepper allergy. On 3/9/23 at 1:15 pm, LPA interviewed Food Services Director, who stated that in January 2023, they served R1 and other residents fish on the alternate menu that was seasoned with Cajun seasoning. Food Services Director states that they forgot R1 has an allergy to pepper until R1 brought it to their attention. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency 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)

Page: 2 of 4

Control Number 29-AS-20230103092831

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 87555(b)(9)	1 2 3 4 5 6 7	87555(b)(9)-General Food Service Requirements, (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. The facility did not meet the requirements as evidenced by:	1 2 3 4 5 6 7	Food Services Director provided an alternate meal to R1. Interim Administrator commits that med-techs will immediately give a copy of the dietary communication form to the Food Services Director. Interim Administrator commits to determining a location for the dietary needs list in the kitchen and ensures staff adhere to it. Interim administrator will send CCL a photo of the list posted by 3/10/23.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the above regulation. Resident #1’s dietary needs were not adhered to which poses 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)

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