405850034-3-1-2022-29-AS-KBUY-CC7V62-20220304150849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 03/01/2022
Date Signed: 03/01/2022 07:13:33 PM

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
07/31/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200731121328

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	MARSH, CHERYL		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 706-0736
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 60	DATE:	03/01/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Emily Villegas, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff caused an injury to a resident while in care
Resident's room was not properly maintained while in care

INVESTIGATION FINDINGS:

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On 3/01/22 at 3:40 pm, Licensing Program Analyst (LPA) Chavez conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial visit was conducted on 08/03/2020 by LPA Darlene Chavez. During today’s visit, LPA met with Emily Villegas, Executive Director and explained the reason for the visit.

This complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Mariana Lomeli. On 08/03/2020, between 11:01 a.m. and 11:19 a.m., LPA Darlene Chavez conducted the initial complaint visit. The LPA met through video chat with Cheryl Marsh, Administrator, and requested copies of documents pertinent to the investigation.

Continued on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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-20200731121328

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: 03/01/2022

NARRATIVE

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Regarding the allegation “Staff caused an injury to a resident while in care,” Investigator Lomeli conducted an interview with the reporting party on 08/06/2020 at 11:20 a.m. and attempted to interview Resident #1 (R1) at 11:55 a.m. Interviews were conducted on 08/20/2020 with the Administrator and staff from 12:00 p.m. to 1:45 p.m. Additional interviews were conducted with staff on 08/31/2020 from 10:00 a.m. to 1:42 p.m. The Administrator was interviewed again on 09/02/2020 at 12:00 p.m. and an interview was conducted with the Resident Services Director at 1:38 p.m. Staff #1 (S1) was interviewed on 09/04/2020 at 12:30 p.m. Facility records, medical records, 911 and Emergency Services reports were also obtained and reviewed.

The Physician Report dated 06/12/2019 listed R1’s primary diagnosis as Parkinson’s Disease. According to the Pre-Placement Appraisal Information and the Needs and Services Plan, both dated 01/02/2020, R1 had a history of falls and required total assistance for ambulating and standby assistance for transfers.

Incident reports were submitted for R1 falls occurring on 07/17/2020 at 9:50 a.m.; on 07/19/2020 at 5:30 a.m.; and on 07/22/2020 at 5:30 p.m. Per the incident report, R1 was without standby assistance when the fall occurred on 07/22/2020. Information obtained through interviews revealed that S1 placed hands on R1 to assist when R1 fell. S1 stated while walking by R1, R1 asked S1 for assistance in getting up out of chair. S1 stood behind R1 and placed both hands on R1’s shoulders in a gripping position to support R1. R1’s hands slipped from the walker due to R1’s feet not being in a correct position and R1 fell face down hitting face on the floor. Staff called 911 and R1 was taken by ambulance to Sierra Vista Regional Medical Center. R1 was diagnosed with a right Supraorbital Hematoma. R1 was discharged from the hospital on 07/29/2020 to a skilled nursing facility due to R1 needing constant 24-hour nursing care since the 07/22/2020 fall.

During the interview with Investigator Lomeli, S1 stated they should not have assisted R1 and should have called direct care staff to assist R1. S1 was not trained to assist residents with transferring and ambulating. S1 was assigned to perform laundry and housekeeping duties.

Based on the information and documentation obtained, the Department has sufficient evidence to support the above allegation. Due to S1’s inexperience, lack of training and lack of knowing R1’s medical history, S1’s attempt to assist R1 caused R1 to fall face forward on the floor, sustaining a right Supraorbital Hematoma. Therefore, the allegation “Staff caused an injury to a resident while in care” is deemed Substantiated.

Continued on 9099-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200731121328

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: 03/01/2022

NARRATIVE

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Regarding the allegation “Resident's room was not properly maintained while in care,” during Investigator Lomeli’s investigation, through interviews and photos, it was found that R1’s bedroom was dirty with carpet stains and food spills. The Administrator, Cheryl Marsh, acknowledged the room was not acceptable. The Administrator, Cheryl Marsh, confirmed that staff had been written up for leaving diaper pads on the shower floor. Based on observations and interviews, the allegation “Resident's room was not properly maintained while in care” is Substantiated.

A $500 immediate civil penalty is assessed today for injury to R1. The Executive Director was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f).

Exit interview conducted, deficiencies cited on 9099-D, civil penalty issued, appeal rights issued, and a copy of this report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20200731121328

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: 03/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Personal Rights To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCL by 3/04/22.
	8 9 10 11 12 13 14	Based on documentation and interviews, S1 was not qualified to assist R1 which caused R1 to fall face forward on the floor sustaining a right Supraorbital Hematoma, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/04/2022 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times…(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit plan on how you will ensure resident rooms are maintained in a clean and sanitary condition. Submit to CCL by 3/04/22.
	8 9 10 11 12 13 14	Based on interview from Administrator and photos – R1’s bedroom was dirty with carpet stains and diaper pads were found on the shower floor, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC9099 (FAS) - (06/04)

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