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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:11:15 PM


Document Has Been Signed on 05/23/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Darlene MarkhamTIME COMPLETED:
12:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted an unannounced case management visit to the facility above. LPA met with Darlene Markham and explained the purpose of the visit.

During the investigation of Complaint #29-AS-20230404090321, additional deficiencies were discovered. LPA Chavez reviewed admission agreements, pharmacy waivers, Residence Council Meeting minutes, and interviewed the interim Administrator.

The facility provided copies of an “Alternate Pharmacy Waiver” document that states “Please be aware that if you select to use an alternate pharmacy other than Avila’s pharmacy of choice, there will be extra fees to consider. Alternate pharmacy medications are not bubble packed an requires additional protocol. If you choose to use your own pharmacy, there will be an additional fee of $200 per month.”

LPA reviewed the Alternate Pharmacy Waiver, which the facility states is a part of their Admission Agreement. The Admission Agreement the facility originally submitted to CCL in their application for licensure does not contain the Alternate Pharmacy Waiver. At the time this complaint was received, the facility had not submitted any changes to their Admission Agreement for CCL to review. Therefore the Alternate Pharmacy Waiver is considered invalid since it was not originally part of the facility’s Plan of Operation/Admission Agreement. It was not submitted to CCL for approval prior to use.

Exit interview, deficiencies cited on 809-D, report and appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
87208(a)

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(a)Plan of Operation. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by:
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 Licensee will refund residents who incurred the unapproved pharmacy charge. Provide list of residents that have been charged and refunded. If the facility is going to charge a fee it will need to be added to the admission agreement and fee schedule submitted to CCL for approval before charging any residents.
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Based on record review, the facility did not comply with the section cited above when they did not submit changes to their Admission Agreement to CCL before implementation, which posed a potential 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: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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