405850034-4-12-2023-29-AS-KBUY-CR9NJP-20230426103041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 04/12/2023
Date Signed: 04/12/2023 05:31:19 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
07/20/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220720160706

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	KARI BOWRON		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 46	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	04:12 PM
MET WITH:	Ruth Ocon, Senior Sales Specialist		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Staff mismanaged resident medications

INVESTIGATION FINDINGS:

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On 4/12/23 at 4:12 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 7/20/22. LPA met with Ruth Ocon, Senior Sales Specialist, and explained the purpose of the visit.

On the allegation, “Staff mismanaged resident medications,” the complainant’s concern was that staff did not order a refill of medication for Resident #1 (R1) and the medication ran out. The complainant says R1 did not receive their medication on three occasions in July 2022 and subsequently incurred adverse symptoms. To investigate, LPA interviewed the administrator, staff and residents and reviewed records.

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: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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-20220720160706

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: 04/12/2023

NARRATIVE

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On 7/20/22 at 1:00 pm, LPA spoke with residents. R1 says that on three occasions in July they were not given a prescribed medication. On 2/3/23, LPA reviewed R1’s medication administration records (MARS) and found that there were three occasions in July 2022 where they were not provided medications as prescribed. R1 stated on 7/4/22 or 7/5/22 they requested their Oxycodone PRN but did not receive it after requesting it. Records indicate on 7/4/22 and 7/5/22, R1 did not receive the Oxycodone PRN. The Oxycodone PRN was refilled every 30 days with 105 pills, with the directions to take it every 6 hours as needed. LPA observed a fax from the facility on 7/6/22 asking for an Oxycodone refill. On 7/26/22 between 11:30 am and 2:40 pm, LPA interviewed the administrator and staff. The administrator was unfamiliar with the alleged medication errors. Staff stated they were aware that R1’s medications were running out and faxed a request to R1’s doctor on 7/6/22 for a refill. The medication was refilled on 7/6/22, and R1 resumed their Oxycodone PRN.

LPA reviewed R1’s Centrally Stored Medications Record for June and July 2022 but did not observe R1’s Oxycodone PRN listed on it.

LPA interviewed med techs about their refill procedure and about R1’s Oxycodone PRN. Med techs stated they usually fax the doctor for refills on R1’s Oxycodone PRN when there are 14-20 pills remaining. Med tech stated, “sometimes the insurance won’t cover it until only a couple of pills are left.” Multiple med techs stated the pharmacy, Pharmerica, tells the facility they cannot fill the prescription because insurance would not cover it. LPA interviewed the administrator who states that she directs med techs to call a prescription in to a local pharmacy or take the resident to the hospital. Multiple med techs interviewed stated R1’s physician is not very responsive to refill requests with one noting, it is “hard to get refills from” them. On 3/27/23, the administrator informed LPA that the refill requests could be obtained from Pharmerica. Administrator provided refill requests for R1 in June 2022 and July 2022, however, the requests did not include a refill for R1’s Oxycodone PRN. On 4/4/23, the administrator provided CCL with a Pharmerica refill request for R1’s Oxycodone PRN which has an Ordered Date of 7/6/22. Administrator stated there were no refill requests available showing a refill was requested for R1’s Oxycodone PRN in June 2022 or prior to 7/6/22 when the refills were needed, and R1 did not receive their medication.

Based on evidence obtained, the allegation, “Staff mismanaged resident medications,” is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, civil penalty issued and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220720160706

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: 04/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed…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:	1 2 3 4 5 6 7	Licensee will conduct training on prescription refills with all staff who assisting residents with medications. Administrator will send CCL a commitment by 4/13/23 stating the training will be conducted by 4/19/23.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above when refills are not filled timely and not given as prescribed, which poses an immediate health and safety to persons in care.	8 9 10 11 12 13 14
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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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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