405850034-11-17-2023-29-AS-KBUY-CY33TS-20231129173225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:49:58 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
03/16/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230316144424

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: 54	DATE:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Darlene Markham, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rachael De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Darlene Markham and explained the purpose of the visit today was to deliver final finding of the complaint allegation.

LPA Chavez conducted the initial 10-day visit on 03/17/2023, conducted interviewed the interim executive director at 10:50am and staff at 1:30pm and 2:03pm, reviewed medication records for Resident 1 (R1) and requested the following documentation: Resident roster, staff schedule, timesheets, and MARS for March 2023. LPA Chavez conducted a subsequent complaint visit on 03/27/2023, interviewed a resident at 11:30am, and reviewed the MAR record for R1. On 04/25/2023 LPA Chavez conducted an interview with witness at 4:17pm.

Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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-20230316144424

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: 11/17/2023

NARRATIVE

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On the allegation: Staff mismanaged resident's medication, on 11/15/2023 LPA De Leon reviewed the complaint, interviews, medication records and audits which revealed the Medication Administration Record (MAR) for R1 showed on 03/01/2023 R1’s 50mg Myrbetriq ER 1 tab daily was not given, and no exceptions or explanation listed, on 03/12/2023 R1 was not given R1’s 35mg of Alendronate Sodium of 1 tab weekly and no exception or explanation listed. On 06/09/2023 in a medication audit for R1 it is noted that R1 had a missed medication Levothyroxine on 05/26/2023. LPA reviewed incident reports from the facility and none of R1’s missed medications were reported to Community Care Licensing. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, civil penalty, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230316144424

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: 11/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/24/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a)A plan for incidental medical and dental care shall be developed by each facility... (4)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	Administrator agreed to continue with monthly medication audits for 2 months, read, review and train med-tech staff in regulation 87465, CCL’s Medication Guide, and facility policy and procedures for passing medications. Provide an up-to-date LIC. 500 with medication technicians listed
	8 9 10 11 12 13 14	Based on record review and audit the Licensee did not comply with the regulation above R1 had 3 missed medications which is a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	along with signed training sheets for each with topic/date/time/hours covered to CCL by due date.
	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: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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