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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:26:40 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
08/23/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230823115643
FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:DARLENE MARKHAMFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 54DATE:
10/16/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Darlene Markham, Administrator/Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not meet resident’s needs.
INVESTIGATION FINDINGS:
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On 10/16/23 at 11:45 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 8/23/23. To investigate, LPA interviewed the executive director, interim administrator, staff, residents, and witnesses on 8/30/23 between 11:25 am and 2:30 pm, 10/12/23 between 11:21 am and 11:38 am, and on 10/13/23 at 10:48 am. LPA met today with Darlene Markham, Administrator/Executive Director, and explained the purpose of the visit.

On the allegation, “Facility staff did not meet resident’s needs,” the complainant was concerned that the facility did not provide Resident 1 (R1) assistance with transporting R1 in their wheelchair and that the facility did not follow the home health care plan in changing R1’s bandages.

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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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-20230823115643
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: 10/16/2023
NARRATIVE
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Interim administrator says a meeting was held on 7/20/23 with R1, Ombudsman, Executive Director, and herself to discuss R1’s concern that staff are no longer able to provide assistance with transporting R1 in their wheelchair. Administrator says that she offered staff to assist R1 with pushing their wheelchair but that there would be an increased care plan and cost associated, and that R1 refused due to the additional costs. Administrator says that at that point, R1 was able to “self-propel” and staff no longer helped R1 with transporting R1 in their wheelchair.

LPA reviewed R1’s Needs and Services Plan dated 8/1/23 which shows that the facility will “Provide for total assist using prosthetic device.”

LPA interviewed R1 who stated that they were in a wheelchair for approximately two weeks due to their motorized scooter breaking down. R1 says they had difficulty moving throughout the facility in a wheelchair due to a physical disability and asked staff to assist. R1 says staff assisted for a few days, but then said they could no longer push resident. R1 confirms that a meeting took place regarding the situation, management said R1 would incur additional fees if staff continued to help so R1 declined due to their inability to pay the extra fees.

Based on the evidence obtained, the allegation is deemed substantiated at this time in that the licensee did not ensure R1 received basic services in transporting resident during a temporary change in mobility.

Regarding the complainant’s concern that staff refused to assist R1 in placing the bandages over skin tears because staff say, "It’s the home health agency that has to assist with them,” the complainant states the facility has known about the bandages since R1 moved in and still force R1 to care for the bandages on their own.

R1 says that home health visits twice a week to change bandages and that facility staff say they are not able to replace R1’s bandages.

LPA reviewed R1’s home health records which do not indicate action items for facility staff. LPA spoke with Witness #1 (W1) from R1’s home health agency who states that facility staff should not assist with R1’s wound care and that only home health nurses should be changing R1’s bandages. Based on evidence obtained, the allegation that the facility did not follow the home health care plan in changing R1’s bandages is unsubstantiated at this time.

Exit interview conducted, deficiency cited, and report and appeal rights given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230823115643
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: 10/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2023
Section Cited
CCR
87464(a)
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Basic Services
(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction... This requirement was not met as evidenced by:
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R1 currently has a working scooter and no longer needs staff assist. Licensee will submit a Statement of Understanding of the regulation cited and will submit to CCL by due 10/17/23.
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Based on interviews and record review, the licensee did not comply with the regulation cited above in that they did not provide basic services for R1 during a temporary mobility issue which poses an immediate health, safety or 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: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
08/23/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230823115643

FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:DARLENE MARKHAMFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 54DATE:
10/16/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Darlene Markham, Administrator/Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility transportation van was not safe for residents.
Facility staff do not treat residents with dignity and respect
Facility staff restricted residents from filing complaints
INVESTIGATION FINDINGS:
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On 10/16/23 at 11:45 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 8/23/23. To investigate, LPA interviewed the interim administrator, executive director, staff, and residents on 8/30/23 between 11:25 am and 2:30 pm, and on 10/12/23 between 11:21 am and 11:38 am. LPA met today with Darlene Markham, Administrator/Executive Director, and explained the purpose of the visit.

On the allegation, “Facility transportation van was not safe for residents,” the complainant’s concern was that the staff will not allow R1 to stay on their motorized scooter while in the van and instead require R1 to sit in a van seat without a seat belt. The complainant states when staff slam on the brakes the residents move around significantly.

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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20230823115643
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: 10/16/2023
NARRATIVE
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R1 says that when they are transported in the facility’s van, staff require R1 to get out of their scooter and sit in a van seat with a seatbelt. R1 says they don’t know why former staff allowed R1 to sit in their scooter in the van and why that has changed. R1 says that their doctor is working on getting R1 a motorized wheelchair because R1 feels they are no longer sitting properly in their current scooter. R1 comments that walkers are folded and laying on the van floor and when staff step on the brakes, they slide to the front seats.

The interim administrator says that R1 came to her about two months ago saying they didn’t feel safe with their scooter strapped down in the van. Administrator told R1 it would be better to transfer to a seat and use the seatbelt or sit in a wheelchair and strap it down.

The van’s driver says R1 does not sit properly in their scooter, that their body is not aligned with the scooter, and does not think it is safe to keep R1 in the scooter while being transported in the van.

Based on evidence obtained, the allegation is deemed unsubstantiated at this time. Staff made attempts to keep R1 safe while being transported.

On the allegation, “Facility staff do not treat residents with dignity and respect,” the complainant was concerned that staff told R1 that there were "special rules" for R1 and another resident but did not know what the rules were. The complainant believes these rules are due to R1 and the other resident being overweight. The complainant was also concerned that staff “constantly state that a rent increase could happen” due to these special rules.

Interim administrator says they treat all residents with dignity and respect and was addressing the situation according to their care plan procedures.

R1 says they were concerned about the rent increase and communicated to management that they were not able to pay but did not feel they were going to be evicted. R1 says they felt staff were treating them with dignity and that their only concern was that staff had difficulty pushing R1 in their wheelchair.

Based on evidence obtained, the allegation is deemed unsubstantiated at this time.

On the allegation, “Facility staff restricted residents from filing a complaint,” the complainant’s concern was that a memo was posted at the front of the facility asking all residents to bring any concerns to the administrator and not the ombudsman. Continued on 9099-C.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20230823115643
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: 10/16/2023
NARRATIVE
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Interim administrator says she did not “put that out to residents.” Executive Director says she does not know of any sign with a statement as such.

LPA reviewed Resident Council and Family Council Meeting minutes for March 2023 to July 2023 and did not find a statement from management regarding the procedure for reporting concerns.

Staff 1 (S1) says they remember a sign posted in the lobby about reporting concerns but does not remember what exactly it read and does not have a copy of it.

Residents interviewed say they were not aware of a posting and are comfortable with discussing concerns either with management or with the ombudsman. One resident mentioned they heard management preferred bringing concerns to them rather than ombudsman but wasn’t certain it was stated in a way that residents couldn’t bring concerns to the ombudsman.

Based on evidence obtained, the allegation is deemed unsubstantiated at this time. LPA advised licensee to ensure communication is clear to residents that they have the option to bring concerns to ombudsmen equally as well as bringing concerns to management.

Exit interview conducted, report given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6