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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:04:15 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
06/30/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230630090818
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: 54DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Darlene Markham, Administrator/Executive DirectorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff financially abused resident in care.
INVESTIGATION FINDINGS:
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On 10/6/23 at 2:50 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced visit to deliver the final findings for an original complaint dated 6/30/23. LPA met with Darlene Markham, Administrator/Executive Director, and explained the reason for the visit.

On the allegation, “Staff financially abused resident in care,” the complainant’s concern was that the former Administrator/Executive Director (ED) “stole” money from a resident. The complainant details that a Christmas Fund was set-up and organized by residents to acknowledge the accomplishments of hourly employees at the facility. Complainant says the family of Resident #1 (R1) received a letter from Resident #2 (R2), who organized the Fund, asking for a donation. Instead of giving the donation to R2 the fund organizer, the family approached the ED about their donation, and the ED instructed them to make the check out to the ED. The complainant says the ED cashed the check and did not forward the monies to the fund organizer for the donation’s intended purpose. To investigate, LPA interviewed the administrator, residents, witnesses, the former ED, and reviewed records. 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: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 3
Control Number 29-AS-20230630090818
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: 10/06/2023
NARRATIVE
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On 7/5/23 at 12:42 pm, LPA interviewed Karen Enciso, current Administrator. Administrator stated that in March or April of 2023, she was made aware by a staff that a $2,000 donation to the Christmas Employee Appreciation Fund 2022 went missing. She explains that the Fund was created by residents, organized by R2, and designed to acknowledge hourly staff for their tenure with the facility. She says she investigated and found that the family of R1 made the donation in December 2022 to the Fund, and the check was written to the ED and cashed by the ED. Administrator explains that since ED was on leave at the time they learned of the issue, human resources called the ED and asked where the $2,000 donation was, to which the ED said they spent it on a Christmas party for the employees but did not have receipts for these expenses. Administrator stated she did not find any receipts and asked employees if ED threw them a party, to which they said that Chinese food was brought in for them on 12/23/22. Administrator verified that the charges for the 12/23/22 food were charged to ED’s business credit card, not paid for with personal monies. Administrator stated she did not call the police to report the missing money but rather suggested to R1’s family to file a police report. R1’s family declined to file a police report on their own. The former ED did not return to work at the facility after being out on leave. The facility credited R1’s account for the amount of $2,000. The facility also did not report the missing money to CCL or the Long-Term Care Ombudsman.

On 7/5/23 at 1:44 pm, LPA spoke with Witness #1 (W1). W1 states that they visited the facility, spoke with the ED, and gave the ED a check for $2,000 for the Employee Christmas Fund. W1 says they received a letter asking for a donation and didn’t feel comfortable giving the money to a resident (fund organizer) so they went to the ED. W1 stated they asked the ED, “Who should I make the check out to?” and the ED responded, “Make it out to me.” W1 says the check was then written out to the ED and handed to the ED. W1 confirms that the check has been cashed. On 8/4/23 at 11:29 am, LPA reinterviewed W1. W1 stated that they received an email on 11/27/22 from the facility’s receptionist on behalf of the Family Council asking for a donation to the Christmas Fund. LPA reviewed the email. W1 says they don’t think the ED used the money for what it was intended which was the Christmas Fund for staff appreciation created by the Resident Council per the email.

On 7/22/23, LPA reviewed a copy of the check from the account of R1, written in December 2022 for the amount of $2,000, made payable to ED with a memo “Christmas Fund…”, and signed by R1’s representative. LPA inspected the endorsement on the back side of the check which appears to match that of the ED’s signature on Licensing reports from 10/14/22 to 2/3/23. LPA reviewed a letter sent to residents and their families who contributed to the Fund in 2022. R1 and their family were not listed as donors in the letter. Continued on 9099-C.

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

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230630090818
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: 10/06/2023
NARRATIVE
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On 7/5/23 at 1:10 pm, LPA interviewed R2. R2 stated that they sent a letter to residents and their families in July 2022, asking for donations to the Christmas Employee Appreciation Fund 2022. R2 explains that the Fund was created by residents to recognize hourly employees, not management, for their tenure at the facility. After R2 distributed the money to the employees for appreciation, R2 stated they sent a letter on 12/27/22 to residents and their families acknowledging their contribution to the Fund. R2 stated they did not acknowledge R1’s contribution because they did not receive a donation from R1 or their family. R2 stated they do not remember receiving a $2,000 check and that they “absolutely did not” receive donations from management.

On 7/24/23 at 4:23 pm, LPA interviewed the ED. The ED stated that in December 2022 they received a check from R1’s family and that the family told the ED to “Treat the staff, take them out to eat, get gifts, do whatever you want.” ED says they spent the $2,000 on “a dinner with the directors and spouses, a magician for a Valentine’s Day party for staff and residents, a pizza party, breakfast at the Madonna Inn and supplies for the staff break room.” According to the ED, R1’s family indicated the money was for staff appreciation, and the ED maintains that they spent all the money on staff appreciation but did not give it to R2 or the Christmas fund organized by R2. On 8/4/23, LPA reviewed photos received from ED on 7/24/23 and 7/25/23. Photos included a copy of the cashed check in question and the ED’s bank statement showing the $2,000 check deposited into their personal bank account. The former ED produced receipts and credit card statements that the ED states show how the money was used. The receipts and credit card statements add up to over $2000. However, receipts could not be produced for every credit card charge. LPA tried to corroborate through staff interviews that the charges and receipts produced match up with staff appreciation (and were not a personal purchase the ED made), but LPA was unable to verify that every dollar went to staff appreciation.

Due to the lack of evidence to conclusively prove the ED misused donated funds, the allegation “Staff financially abused resident in care,” is deemed unsubstantiated at this time. The former ED no longer works at the facility. CCL recommends that the facility remind all staff that they should not accept donations for the Resident Council Christmas Fund and direct the donor to the Resident Council, staff should not ask that checks be made out to their individual name, and staff should not cash checks for donations into their personal accounts.

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: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3