405850034-6-19-2024-29-AS-KBUY-D6F56C-20240620194030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 06/19/2024
Date Signed: 06/19/2024 05:00:51 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
11/29/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20231129084124

FACILITY NAME:	AVILA SENIOR LIVING AT DOWNTOWN SLO		FACILITY NUMBER:	405850034
ADMINISTRATOR:	DARLENE MARKHAM		FACILITY TYPE:	740
ADDRESS:	475 MARSH ST		TELEPHONE:	(805) 541-4222
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	100	CENSUS: 49	DATE:	06/19/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Darlene Markham, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of supervision resident was able to leave the facility unassisted.
Facility did not seek medical attention for resident's change in condition.
Staff assigned to supervision of resident lacks required trianing.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) De Leon conducted a subsequent visit to the facility above to deliver final findings of the complaint allegations. LPA met with Darlene Markham, Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 12/01/2023 requested records and interviewed staff at 1:15pm, 1:30pm, 1:45pm, and 2:15pm. LPA completed additional interviews with residents on 5/16/2024 at 11:15am and 05/30/2024 at 11:09am. LPA reviewed records on 06/18/2024 and requested additional records on 06/18/2024. LPA reviewed records on 06/19/2024.

On the allegation: Due to lack of supervision resident was able to leave the facility unassisted. LPA reviewed documentation, incident reports, and conducted interviews which revealed R1 had major change of conditions on 11/24/2023 while being on an outing and on 11/26/2023 was still left able to sit out front of the facility in a chair without staff presence, due to this lack of supervision, the staff had to bring it to
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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 6

Control Number 29-AS-20231129084124

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: 06/19/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

the care staffs attention R1 was wandering away from the facility, staff tried to re-direct R1, R1 aggressed at staff and was able to walk down the front parking lot and get onto a busy street before Wellness Care staff were able to re-direct R1 back into the facility. The facility did not provide a 1 on 1 care to R1 after this incident. Charting notes indicated the family would provide 1 on 1 care as of 12/01/2023 till R1 was relocated on 12/07/2023.

Based on the evidence this allegation is Substantiated at this time.

On the allegation: Facility did not seek medical attention for resident's change in condition. LPA De Leon requested and reviewed the Charting notes from 04/14/2022- 12/07/2023 for R1. The following was revealed in the charting notes:
On 04/14/2022 R1 had a fall.
On 05/12/2022 R1 had a fall
On 06/24/2022 a Care conference was held for R1 to discuss a reassessment with physician to complete a new LIC 602A. ( LIC 602A dated 06/16/2022)
On 11/25/2022 R1’s daughter brought a MD order saying allowed to leave R1 assisted living facility with R1's walker and accompanied by a friend /another resident.
On 11/26/2022 R1 had a fall.
On 06/08/2023 R1 had a fall and ER visit.
On 06/20/2023 R1 had fall on the 4th floor not part of the assisted Living portion of the building, 911, ER then discharged.
On 07/08/2023 R1 showed signs of confusion, requesting a UA based on escalating confusion.
On 07/09/2023 R1 had repeated directions given at 3:00am, 4:46am, and 8:00am.
On 07/10/2023 R1 had a change in behavior with wandering and redirection out front of the facility. UTI order requested, send out if no reply.
On 07/11/2023 PT visit fall prevention, repeated over and over in hopes of recall, garbled speech, unable to explain self, difficulty following directions, declining medically and physically.
On 07/13/2023 PT visit R1 found confused.
On 07/14/2023 R1 more confusion today.
Continued 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20231129084124

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: 06/19/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 07/16/2023 R1 confused with reassurance by staff.
On 08/08/2023 R1 accused staff of taking supplies, family wants less checks on R1.
On 08/17/2023 R1 Change in behavior, incident of aggression with staff, staff reported to Administrator.
On 08/18/2023 R1’s family was informed of incident, family does not think confusion is a UTI, still waiting on an order, Family only wants checks 2 x per day, R1 went to Wellness stating no bad intentions and R1 was confused.
On 08/19/2023 R1 change of condition, anxious and confused, forgetful and reminders.
On 08/22/2023 R1 confused on which room was R1’s.
On 09/06/2023 Dr. responded to fax sent 08/19/2023 from staff to consider R1 for clinic visit due to frequent anxiety and confusion, family to call doctor regarding medication.
On 09/09/2023 R1 noted with more confusion, talking about things that do not make sense.
On 09/15/2023 R1 confused with staff assistance.
On 09/30/2034 R1 incredibly confused throughout the day, family acknowledged R1 was more uneasy than usual.
On 10/13/2023 R1 confused about time redirected by staff.
On 10/15/2023 R1 follow up from fall, no complaint of pain, Band-Aid to right leg, no fall was noted in prior notes.
On 10/31/2023 R1 confused about time, staff re-directed.
On 11/18/2023 R1 confused about time, staff re-directed.
On 11/24/2023 R1 left for visit with family, R1 had a melt down and was very confused, updated family of days and nights mixed up, wandering and re-direction, Family stated they know R1 is heading for memory care sooner than later and if the facility memory care is not ready soon R1 will be moved, R1 returned to facility and was later confused about time, staff re-directed.
On 11/25/2023 R1 confused about time, staff redirected.
On 11/26/2023 R1 behavior episode with aggression, wandering, yelling, safety issues, resisted help and redirection, hitting, and 911 called, R1 later was still clearly distressed, confused, speaking with out making sense, continuously tried to leave facility, and family came to facility to stay with R1 for the night.
On 11/27/2023 Per family R1 became very agitated, aggressive to family, family stated R1 does not belong at the facility, family left the facility.
On 11/30/2023 Conference held for R1, R1 will be assessed for new community admission on 12/02/223, Dr. will be here 12/04/2023 to do a new LIC 602A, Family will arrange 1 on 1 companion by tomorrow.
On 12/07/2023 R1 moved to higher level of care, discharged from the facility. Cont. 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20231129084124

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: 06/19/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 had an LIC 602A dated 06/16/2022 with a diagnosis of frequent falls, A-Fib and MCI. R1 was not able to leave the facility unassisted. Dr. note noted in charting notes dated 11/25/2022 to allow for friends and resident to assist R1 on outings out of the facility.

R1 had an LIC 602A dated 12/04/2023 for admission into a new facility with a primary diagnosis of Dementia.

According to the charting notes starting from the end of June 2023 to the end of November of 2023 R1 had been displaying changes in condition and changes in behaviors and the facility did not seek timely medical attention for R1 changes in condition until R1 became aggressive, wandered into a busy city street, 1 bicyclist bystander stopped to help resident in the street, it took several staff and 1 bicyclist bystander to get R1 redirected back into the facility, where R1 continued to show confusion and aggression, 911 was called out and R1 was not transported at that time. R1 was seen by a doctor on 12/04/2023 for admission into a new facility with change of condition. R1 moved out of the facility on 12/07/2023.

Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff assigned to supervision of resident lacks required training. LPA De Leon requested and reviewed annual training records for 2023 on all Wellness Care staff and Med-techs working in November 2023. The facility had a total of 9 Care Staff/Medication Technician (Med-Tech) working and 1 LVN working in November of 2023. The 9-care staff/Med-tech were reviewed for the annual 20 hours of training requirements. 1/9 staff had 25 plus hours of annual training, 2/9 staff had 11 hours of annual training for 2023, 1/9 staff had 13 hours for 2023, 1/9 staff had 14 hours for 2023, 2/9 staff had 16 hours, 1/9 staff had 19 hours and 1/9 staff had 6 hours for 2023. LVN had a current license, a current RCFE Administrator Certificate and 40 plus hours of continuing education and facility in service training's. The staffing are not meeting the required amount of annual training hours or subjects/topics. Training records will need to have the time, date, and hours for each subject/topic covered. The front desk staff is not assigned to resident care.

Based on the record review this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, 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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 29-AS-20231129084124

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: 06/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/21/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review 87464, provide training to all staff on the responsibilities of each staff for reporting, redirecting of residents that cannot leave the facility unassisted, facility statement and procedures to keep this incident for reoccurrence.
	8 9 10 11 12 13 14	Based on record review the License did not comply with the regulation above R1 was able to leave the facility unassisted, get into the busy street before being re-directed by care staff which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Provide proof of training with staff signatures and up to date LIC 500.
Type A 06/21/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a)...(4)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 was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review 87468, 87468.1 and 87468.2 provide training to all Wellness staff on duties for reporting changes in conditions, doctor follow-up/coordination, care coordination meetings with updated LIC 602A’s, ANS, when to seek timely medical attention for changes in
	8 9 10 11 12 13 14	Based on record review the Licensee did not comply with the regulation above the staff did not seek medical attention when changes in R1 condition/behaviors were noted which posed an immediate person rights risk to residents in care.	8 9 10 11 12 13 14	condition/behaviors, mandated reporting, facility staff responsibilities, personal rights, provide up to date LIC 500, proof of training with staff signatures and materials used.

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20231129084124

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: 06/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/26/2024 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	(c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to have all Wellness staff take required annual training covering all required topics and hours with trianing records meeting all requirements of time, date, hours, staffs and trianers name/titles/information.
	8 9 10 11 12 13 14	Based on record review the Licensee did not comply with the regulation above, care staff did not meet the annual training of subjects and hours, which possess a potential Health, Safety and Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6