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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/11/2024
Date Signed: 03/11/2024 05:50:24 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
03/06/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240306103155
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: 48DATE:
03/11/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Darlene Markham, AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not give resident medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10 day Complaint visit to the facility above. LPA met with Administrator Darlene Markham and explained the purpose of the visit.

LPA requested the following records: Staff Roster with telephone numbers, Resident Roster, Wellness records for January 2024-March 2024 on R1's for notes, charting, Medication Administration Records (MAR) with daily medications and prescribed medication as needed (PRN), Centrally Stored Medications and Destruct Records (CSMDR), Doctor's orders for all medications and Doctor orders for Medication Butal-CaffAcetamin-COD PRN all orders for all dates.

On the allegation: Staff did not give resident medication as prescribed. LPA reviewed medication records at 12:00 PM for Resident 1(R1) from 01/2024-03/2024. R1 was prescribed Butalibital/ACEt/Codeine 1 tablet TID PRN on 01/04/2024 by R1's doctor effective 01/04/2024. Around 12:45pm LPA went into the wellness department took photographs and review the bubble medication packets for that medication and it had the order correct 1 tablet TID PRN dated 02/02/2024.
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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
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 3
Control Number 29-AS-20240306103155
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: 03/11/2024
NARRATIVE
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 LPA reviewed the Wellness charting for R1 at 2:56pm which had a note dated 12/25/2023 at 5:45pm R1 wants R1's pill TID and to be given at 6am, 2pm, and 10pm, left a note for Medtech communication log by staff 1 (S1), then another note dated 02/18/2024 10:04pm from S1 stating the order was only for BID PRN and R1 had already had it at 6am and 3pm so S1 refused to give it again even though R1 said it was to be TID PRN and that is the way R1 had been getting over the last month. R1's charting notes for 02/19/2024 at 12:08am had another note from S1 stating that R1 was mad and yelling that R1 wanted the medication and S1 refused to give it again due to the order only being BID PRN, S1 stated S1 needed to get the order clarified because S1 could only give it as it was written on the MAR. According to the MAR review for February 2024 the medication was listed twice, 1 to be discontinued on 02/19/2024 for twice daily and another 1 was ordered for three times daily. In reviewing the PRN section on the MAR from 02/01/2024-02/29/2024 the medication had been given 14 times at three times per day and given 12 times at twice per day, 1 time at four times per day and 2 days it was not given at all. LPA reviewed the doctors orders and clarification pages on 08/30/2023 the medication was a PRN given every 4 hours as needed not to go over 6 times per day, on 10/06/2023 the doctors order changed to 1 tab PD BID PRN, then on 02/19/2024 the doctor faxed the facility that the current order was 1 tablet TID PRN due to R1's request at 8:42 am, then on 02/19/2024 the Wellness Director faxed a note to the doctor if the doctor could clarify the original date the order went to TID three times per day and the doctor responded it changed from BID to TID on 01/04/2024. LPA reviewed the MAR from January 2024 for the medication, it was written on the MAR as twice daily as needed but in reviewing the PRN section it was given more than 2 times per day on several occasions. The facility was missing the original order for the medication to be given three times per day, it had been sent to the pharmacy by the doctor on 01/04/2024 and the medication bubble packs were updated to 3 times per day but the wellness staff at the facility never updated the MAR to reflect the change or clarified the change with the doctor until R1 complained on 02/19/2024 and had the doctor re-fax the order to the facility so R1 could get R1's medication as prescribed. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, civil penalty assessed, 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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240306103155
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: 03/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...:(4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Administrator agreed retrain wellness department on doctors orders and updating the MAR and conduct and audit of medications & PRN's done for 03/2024 with doctors orders, MAR and CSMDR and provide poof of trianing & audit to CCL.
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Based on the records review the Licensee did not comply with the reagulation above R1 was not give a PRN medication when requested which poses a potential health, safety and residents risght risk 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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3