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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850034
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:00:01 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
10/11/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20241011090952
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: 41DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Darlene Markham, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff provided the incorrect medication to resident in care.
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 Darlene Markham, Administrator and explained the purpose of the visit.
LPA De Leon requested the following records: Resident Roster, Staff Roster with telephone numbers, R1's LIC. 602A Physicians report, R1's Medication list, and R1's charting notes for October 2024. LPA interviewed staff and residents.
On the allegation: Staff provided the incorrect medication to resident in care. Staff 1 (S1) provided residents morning medication in the dining room on Sunday October 6, 2024. Resident 1 (R1) took the cup of pills from S1 and noticed that they were not the pills R1 takes. S1 was distracted by the residents at the dining table asking questions and that is what led to S1 providing R1 the wrong cup of pills. R1 gave the pills back to S1 and did not take any of the wrong pills. S1 provided R1 the correct pills to take. If R1 had not known the pills R1 takes, R1 would have taken the wrong medication. Based on the evidence S1 error in providing R1 with the wrong medication therefore the allegation is substantiated at this time.
Exit interview conducted,deficiency cited,civil assest, copy of report and appeal rights printed for Administrator.
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: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 2
Control Number 29-AS-20241011090952
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: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
CCR
87465(a)(4)
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(a) ...(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 to retrain, retest and shadow S1 before S1 provides assistance with resident medications. Send proof to CCL.
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Based on interviews the Licensee did not comply with the regulation above, S1 provided R1 the incorrect medication which poses a potential Health & Safety 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: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
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