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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850034
Report Date: 06/28/2024
Date Signed: 06/28/2024 03:49:48 PM


Document Has Been Signed on 06/28/2024 03:49 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:
06/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darlene Markham, Administrator TIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management incident visit to the facility. LPA met with Administrator Darlene Markham and explained the purpose of the visit.

Witness 1 (W1) called LPA on 06/27/2024 re: Resident 1 (R1) being in a Skilled Nursing Facility (SNF).

LPA checked incident report folders and emails from facility. LPA was unable to locate a incident report for 05/28/2024 for R1.

LPA requested a copy of the incident report for R1 and proof it had been sent to CCL.

Administrator was able to pull up copy of incident report for R1 from computer but was unable to retrieve a printed copy with fax confirmation.

R1 had a fall and pressed R1's pendant, 911 was called, R1 was transported, R1 was discharged to SNF for rehab, assessment will be done 07/01/2024, R1 will be discharged on 07/03/2024 and return to community.

Administrator provided LPA with a copy of the incident report for R1.

Exit interview conducted, deficiency cited, copy of report and appeal rights provided to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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 06/28/2024 03:49 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: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87211(a)(1)

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(a)...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings...This requirement was not met as evidenced by:
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Administrator agreed to print and give LPA a copy of the indient report for R1 and read section 87211.
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Based on record review the Licensee did not comply with the regulation above, the facility did not submit an incident report for R1 for the incident of 05/28/2024 which poses a 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: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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