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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:49:42 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
04/12/2023 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20230412183338
FACILITY NAME:AVILA SENIOR LIVING AT DOWNTOWN SLOFACILITY NUMBER:
405850034
ADMINISTRATOR:ERIKA HAMPEFACILITY TYPE:
740
ADDRESS:475 MARSH STTELEPHONE:
(805) 541-4222
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:100CENSUS: 53DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Darlene Markham, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility has insufficient staffing to meet resident needs
Resident's call buttons were not responded to timely
Administrator was not on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Darlene Markham and explained the purpose of the visit.

The initial complaint visit and investigation was conducted by LPA Darlene Chavez on 04/14/2023 at 2:45pm. LPA interviewed Senior Sales Specialist and staff, reviewed records, and requested the following documentation: Staff timesheets, call button records, Manager on Duty schedule, Wellness schedule for 4/14/23 through 4/16/23, Physician Report, assessment, staff call out policy, and personnel records. LPA De Leon took over the investigation reviewed complaint, documents received and requested additional documents on 02/07/2024.

Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 4
Control Number 29-AS-20230412183338
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: 02/08/2024
NARRATIVE
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On the Allegation: Facility has insufficient staffing to meet resident needs. On 03/30/2023 the facility had a Non-compliance conference with Community Care Licensing (CCL) to discuss the issues of absence of supervision; insufficient staffing; medication errors; training; spoiled food and improper handling/storage of food; physical plant issues; and lack of a qualified administrator, and the facility plan is to bring all these issues into compliance. On 04/10/2023 on the Noc shift a staff called off leaving only one staff on the floor which the plan requires 2 staff to be present on the floor during the NOC shift to remain in compliance in case anything happens during the shift the facility can act timely and safely. Interviews with staff revealed the facility did have a call off that night and only 1 staff was left on shift. Several call buttons were not answered timely during that NOC shift which poses additional danger if any urgent matter had arisen. Based on the evidence this allegation is deemed Substantiated at this time.

On the Allegation: Resident's call buttons were not responded to timely. 2 residents showing Resident 1 (R1) and Resident 2 (R2) had both used the call button to summons staff for assistance and neither call was answered timely during the NOC shift in 04/10/2023. Interviews revealed a staff called off on the Noc shift and the staff left on duty worked alone on the floor that shift. Based on the evidence this allegation is deemed Substantiated at this time.

On the Allegation: Administrator was not on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. On 03/30/2023 the facility had a Non-compliance conference with Community Care Licensing (CCL) to discuss the issues of absence of supervision; insufficient staffing; medication errors; training; spoiled food and improper handling/storage of food; physical plant issues; and lack of a qualified administrator, and the facility plan was to bring all these issues into compliance. The facility had an interim administrator on record during the month of April 2023 and that administrator left the facility unattended without a licensed administrator present for at least two days on 04/10 & 4/11, 2023. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230412183338
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87415(a)(6)
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(a)The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. ... (6)The requirements of this section shall not prohibit compliance with additional supervisory requirements required by the State Fire Marshal. This requirement was not met as evidenced by:
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The Administrator agreed to have two staff awake and immediately available on the NOC shift in case of emergency. If someone calls off an on-call staff must be called in to fulfill the shift hours, executive staff must find coverage. The NOC shift, Executive Staff, and on-call staff will- cont.
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Based on interview and record review the Licensee did not comply with the regulation above, a staff called off for the Noc shift and the position was not filled to have two awake staff on shift at night which poses a potential Health, safety, and resident rights risk to residents in care.
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complete training on two emergency drills; one for fire scenario and one for earthquake, be trained in the facility Emergency Plan LIC 610E, Emergency evacuation chair, the company policy and procedures for Send proof of training, materials and statements of understanding to CCL.
Type B
02/15/2024
Section Cited
CCR
87415(a)(5)
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In facilities required to have a signal system, ... at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement was not met as evidenced by:
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Administrator agreed to train all PM and NOC MT/Caregiver staff and on call staff on facilities policy and procedures for answering call buttons timely during the night shifts. Provide an up-to-date LIC 500, copy of training material used and training sheet with all staff names/signatures attending.
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Based on interviews and records review the Licensee did not comply with the regulation above, a staffed called off leaving 1 awake staff on the floor and residents call button were not being answered timely which poses a potential Health, Safety, and 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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230412183338
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87405(a)
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(a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by:
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Administrator agreed to be at the facility according to the LIC 500 days/hours and be free from other responsibilities to permit adequate attention to the management and administrator of the facility. If any time is taken a substitute meeting the qualifications will be on the -cont.-
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Based on interview the Licensee did not comply with the regulation above, Administrator was not at the facility for 2 or more days as required by the NCC to remain in compliance which poses a potential health, safety and residents’ rights risk to residents in care.
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facility premises and all staff and residents will be informed of the substitute’s name/number and an LIC 308 designation will be sent to CCL. Send a copy of updated LIC 500 with Administrator days/hours and a statement of understanding from the administrator meeting this requirement and how they plan to meet this requirement.
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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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4