Avila Senior Living at Downtown SLO sits right in the heart of San Luis Obispo, in the 93401 neighborhood, and offers a wide range of care for older adults, like independent living, assisted living, memory care, respite care, and skilled nursing, and you've got all sorts of options here if you're looking for a place that'll fit your changing needs. This community belongs to Pacifica Senior Living and you'll find a mix of studio, one-bedroom, two-bedroom, and deluxe apartment homes, all with things like vinyl or hardwood floors, full kitchens or kitchenettes, washer and dryer units, walk-in or roll-in showers, central air and heating, plus patios or balconies if you want some outdoor air, and there are nice touches like skylights, spacious closets, high ceilings, scenic views, and a glass-topped atrium.
They've got good accessibility too, since the building is wheelchair friendly and there are handrails, accessible showers, elevators, and gated entry for safety, and you'll get high-speed internet, package receiving, off-street surface parking, and pet-friendly rules as long as your dog or cat is under 30 pounds and you pay a deposit, with pet care available for folks who need the help. The grounds have walking trails, a courtyard, rooftop garden and patio, outdoor grilling area, and there are shared spaces inside like a movie theater that shows nightly movies, a library with computers, an onsite salon and spa, a fitness center with a pool, and different community rooms for activities or relaxing. Families appreciate the clean and welcoming look-reviews often mention how friendly the staff is, since they're known for being helpful and joyful, and the whole building feels like home.
Avila Senior Living plans activities to keep people active and social, with daily programs, exercise and art classes, movies, community events, scenic drives, outings, and both onsite and offsite events and devotional services. Dining is a highlight here, since you can eat chef-prepared meals in the dining room or have in-room dining if you like privacy, and they've got vegetarian choices and nutrition in mind, and there's a beautician onsite for those who like to keep up appearances. For care services, the staff is around 24 hours for emergencies and daily help, and care plans are built from the very start with input from residents and families, focusing on what each person needs, whether it's help with daily activities, medication, memory support for dementia or Alzheimer's, skilled nursing, hospice, or palliative care.
Housekeeping, laundry, and even dry-cleaning are handled, so people don't have to worry about keeping things tidy. Transportation is simple too-there's scheduled rides, complimentary rides for local trips, paid options for out-of-area, and parking for those who still drive. People wanting independence find good support here, since the independent living side lets residents have a low-maintenance, active lifestyle but still have help nearby if they ever want it. Assisted living covers personal assistance, and the memory care program gives special attention, structure, and mental engagement for folks dealing with memory issues. Short-term stays for recovery or caregiver breaks are possible through respite care.
The whole place really centers on the needs of seniors, offering a comfortable setting, friendly staff, and a strong focus on safety and health, while trying to keep life active and meaningful for both individuals and couples. There's a glossary and planning resources for families, plus some helpful tools for caregiving right from the start, so everyone feels prepared and supported. Overall, Avila Senior Living offers a steady mix of supportive care, pleasant surroundings, engaging programs, and flexible options to fit many stages of aging in downtown San Luis Obispo.
People often ask...
Avila Senior Living At Downtown SLO offers competitive pricing, with rates starting at a cost of $3,250 per month.
Avila Senior Living At Downtown SLO offers independent living and assisted living.
There are 29 photos of Avila Senior Living At Downtown SLO on Mirador.
The full address for this community is 475 Marsh St, San Luis Obispo, CA, 93401.
Yes, Avila Senior Living At Downtown SLO offers respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
State of California Inspection Reports
163
Inspections
45
Type A Citations
47
Type B Citations
6
Years of reports
02 May 2025
02 May 2025
Closed the site and relocated all residents; remaining residents were independent and not receiving care or supervision from staff, with dining, housekeeping, activities, and maintenance continuing for them, and the operation was no longer licensed to provide care.
§ 9058
04 Apr 2025
04 Apr 2025
Identified three lawsuits against the company’s entities—$25 million in Bakersfield, a photography case against a property, and a SNF-related case in Healdsburg. Found no financial impact to properties, residents, or staff, no vendor issues, and that the bankruptcy did not affect the communities since the management company had already changed, with changes communicated to residents.
§ 9058
22 Jan 2025
22 Jan 2025
Investigated allegation that staff spoke to a resident in an inappropriate manner and the allegation of illegal eviction; found insufficient evidence to support either claim after interviews and review of notes.
10 Jan 2025
10 Jan 2025
Investigated allegation that staff mismanaged residents' medications; interviews and records did not reveal any medication being dropped or withheld, and no evidence of mismanagement was found.
24 Dec 2024
24 Dec 2024
Found the eviction of a resident for a stage 3 wound no longer appropriate, as the latest medical records show the wound is no longer a prohibited condition; therefore the eviction must be rescinded.
29 Oct 2024
29 Oct 2024
Investigated two allegations—illegal eviction and retaliation against a Resident Council member. Found insufficient evidence to support either claim.
16 Oct 2024
16 Oct 2024
Identified a dementia diagnosis for a resident based on a physician's report dated 11/01/2022, which needed updating. Conducted an exit interview, cited a deficiency, and assessed a civil penalty.
16 Oct 2024
16 Oct 2024
Identified a staff error where the wrong medication was offered to a resident during morning meds, caused by distraction from other residents. The resident noticed the pills were not theirs, did not take them, and the correct pills were subsequently provided.
26 Sept 2024
26 Sept 2024
Investigated allegations that a resident was billed for laundry services despite SSI status and that staff harassed the resident; found the laundry charges resulted from a signup error, were credited, and the harassment claim was unsubstantiated.
14 Aug 2024
14 Aug 2024
Determined that the allegation that staff did not comply with emergency disaster plan requirements arose during a 07/18/2024 cooking-related alarm that tripped building-wide; staff evacuated residents in the common areas but did not inform residents in apartments that it was a false alarm.
14 Aug 2024
14 Aug 2024
Confirmed failure to adequately communicate during a false alarm incident.
§ 87224(a)(4)
28 Jun 2024
28 Jun 2024
Identified a resident fall with pendant activation; 911 was called and the resident was transported to a skilled nursing facility for rehabilitation, with an assessment planned. Missing hard copy of the 05/28/2024 incident documentation; electronic version existed but there was no fax-confirmed print.
§ 87211(a)(1)
28 Jun 2024
28 Jun 2024
Identified a lack of documentation for a resident incident involving a fall and subsequent hospitalization at the facility.
§ 87465(a)(4)
20 Jun 2024
20 Jun 2024
Investigated allegation that staff did not seek timely medical attention for a resident; not found to be supported.
Investigated allegation that staff did not assist a resident with obtaining prescribed medication; not found to be supported.
20 Jun 2024
20 Jun 2024
Investigated allegations that staff did not seek timely medical attention for a resident or assist with obtaining prescribed medication; both allegations determined unsubstantiated.
19 Jun 2024
19 Jun 2024
Identified lack of supervision that allowed a resident to leave unassisted and wander into a busy street, with 1-on-1 care not provided as planned. Identified delays in seeking medical attention for changing condition and insufficient staff training hours, evidenced by multiple falls, escalating confusion, and incomplete training records.
§ 87411(c)
§ 87464(f)(1)
§ 87468.2(a)(4)
19 Jun 2024
19 Jun 2024
Found that a resident experienced a change in condition and behavior from late June 2023 through November 2023, and timely medical attention was not provided. Found that a dementia diagnosis was added in December 2023 and there was no dementia plan of operation, so the resident should not have remained and moved out on 12/07/2023.
19 Jun 2024
19 Jun 2024
Confirmed lack of supervision leading to resident leaving unassisted, failure to seek medical attention for resident's change in condition, and lack of required training for staff assigned to supervision.
§ 87208(c)
29 May 2024
29 May 2024
Identified eviction-threat allegation as substantiated; the retaliation against a resident council member remained unsubstantiated.
§ 87468.1(a)(3)
29 May 2024
29 May 2024
Substantiated an incident involving counseling for inappropriate behavior, language, and conduct towards staff. Unsubstantiated retaliation against a resident council member.
§ 87212(b)(2)
28 May 2024
28 May 2024
Investigated and identified that the operator did not respond to the Family Council Chair's written concerns and recommendations within 14 days. This resulted in a daily civil penalty of $250 and an invoice being issued.
§ 1569.158(f)
28 May 2024
28 May 2024
Found that eviction notices issued to two residents were retaliatory in nature tied to Family Council involvement. Identified retaliation against the Family Council chair, including delays and lack of warnings to residents.
§ 1569.158(j)
§ 87468.2(a)(20)
28 May 2024
28 May 2024
Confirmed illegal eviction based on false allegations. Identified retaliatory actions against Family Council member.
23 May 2024
23 May 2024
Investigated a complaint alleging the use of an alternate pharmacy waiver not included in the original admission agreement and not submitted for approval; found the waiver invalid.
23 May 2024
23 May 2024
Found that an Alternate Pharmacy Waiver wasn't in the original Admission Agreement and there was no evidence staff interfered with residents' medical decisions. Found that a letter restricting media access did not violate residents' right to visitation, since no resident invited media and privacy protections were maintained; the second allegation deemed unsubstantiated.
23 May 2024
23 May 2024
Investigated allegations of staff interference in residents' medical decisions and found insufficient evidence, while also reviewing claims of visitation rights violations and determining they were unfounded.
§ 87208(c)
10 May 2024
10 May 2024
Investigated illegal eviction of a resident; found the eviction unlawful at the time and subsequently rescinded.
10 May 2024
10 May 2024
Identified hot water issues across several units, with readings from 65°F to 130°F and many measurements outside the required 105–120°F range, supporting the allegation that hot water was not reliably available.
§ 87303(e)(2)
10 May 2024
10 May 2024
Confirmed inadequate hot water temperatures in multiple rooms at the facility.
19 Apr 2024
19 Apr 2024
Found the allegation that apartments were not clean, safe, sanitary, and in good repair; moisture issues were present in bathroom areas, and repairs were completed.
19 Apr 2024
19 Apr 2024
Identified that the Licensee failed to promptly respond to communications from the residents' responsible party; by 04/19/2024, no written responses had been provided.
§ 87468.1(a)(9)
19 Apr 2024
19 Apr 2024
Confirmed allegation regarding cleanliness and repairs in two specific apartments, repairs were completed to address the issue.
§ 87224(a)(4)
11 Mar 2024
11 Mar 2024
Identified ongoing repairs not completed, including drainage in a storage area, roof leaks over units 202–205, and a washer out of order; mold testing in unit 202 was negative, with results and next steps still pending. Imposed a civil penalty for repeat violations after an exit interview with the administrator.
§ 87303(a)
11 Mar 2024
11 Mar 2024
Found that staff did not give the resident medication as prescribed. MARs and doctor orders were not consistently updated, resulting in dosing discrepancies from January through February 2024.
11 Mar 2024
11 Mar 2024
Identified deficiencies in repairs and maintenance at the facility during the visit.
§ 87465(a)(4)
22 Feb 2024
22 Feb 2024
Identified ongoing work in Apt 118 expected to finish next week; storage room drainage not completed; Apt 202 work not completed; atrium peeling paint and paint bubbles not fixed, skylight leaks fixed; roof leaks over Apt 202-205 not completed; rotted wood trim on the outside not fixed. Exit interview conducted; daily civil penalties assessed on the original complaint visit; appeal rights emailed to administrator.
22 Feb 2024
22 Feb 2024
Identified multiple maintenance issues during the visit.
16 Feb 2024
16 Feb 2024
Reviewed randomly selected resident records with the administrator and toured the dining room, kitchen, and other common areas, noting that additional time was needed to complete the annual continuation visit. Scheduled a return at a later date to finish, and an exit interview was conducted.
16 Feb 2024
16 Feb 2024
LPA conducted an annual visit, reviewed resident records, toured common areas, Dining Room and Kitchen, and will return to complete the visit at a later date.
13 Feb 2024
13 Feb 2024
Conducted a 1-year annual visit, reviewed rosters, liability insurance, emergency and disaster plan, and quarterly drills; toured multiple apartments and common areas with the administrator and maintenance director; will require additional time and return at a later date.
13 Feb 2024
13 Feb 2024
Inspections were conducted at the facility, including checks of resident and staff rosters, emergency plans, and quarterly drills. Various areas within the facility were inspected to ensure compliance with regulations.
08 Feb 2024
08 Feb 2024
Found that the 2022 injury resulted from staff actions during assistance, and noted that a prior citation had been issued. Found insufficient evidence to prove that staff did not safeguard belongings and insufficient evidence that staff took the resident's money.
08 Feb 2024
08 Feb 2024
Found that on 04/10/2023 the night shift operated with only one staff member on the floor after a call-off, resulting in delayed responses to resident call buttons. Found that no licensed administrator was on site for at least two days (04/10 and 04/11/2023), with an interim administrator in place earlier in April 2023.
§ 87415(a)(5)
§ 87415(a)(6)
§ 87405(a)
08 Feb 2024
08 Feb 2024
Found that a refund was issued to the resident's authorized representative after move-out, with receipt confirmed by the family. Found that no eviction notice was issued to the resident or their authorized representative.
08 Feb 2024
08 Feb 2024
Found insufficient staffing to meet resident needs, call buttons not responded to timely, and absence of administrator on premises for extended periods.
25 Jan 2024
25 Jan 2024
Found mold and extensive cleaning and repair needs in several areas, including a storage area, apartments, and common spaces, with leaks, water damage, and damaged trim noted. Identified staffing shortages requiring a maintenance director, an activity assistant/driver, and a housekeeper, with recruitment ongoing and offers extended to candidates pending clearance.
§ 87303(a)
§ 87411(a)
25 Jan 2024
25 Jan 2024
Confirmed allegations of cleanliness and maintenance issues at the facility, as well as staffing deficiencies.
§ 87208(a)
17 Nov 2023
17 Nov 2023
Found that a resident's medications were not given on 03/01/2023 (50 mg Myrbetriq ER 1 tab daily) and 03/12/2023 (35 mg Alendronate Sodium 1 tab weekly), with no exceptions or explanations listed. Noted a missed Levothyroxine dose on 05/26/2023 and that none of the missed medications were reported to licensing.
17 Nov 2023
17 Nov 2023
Confirmed mismanagement of resident medication and cited deficiency.
02 Nov 2023
02 Nov 2023
Found that an emergency exit gate was locked and bolted from the outside, blocking a designated exit; maintenance fixed it so the door opens when the bar is pushed, and it was advised that it must stay unlocked. A deficiency was cited and a civil penalty assessed.
02 Nov 2023
02 Nov 2023
Found issues with proper food storage, including no hairnets available, kitchen staff not wearing hairnets, uncapped foods in the refrigerator, and an open bag of frozen food not sealed. Identified extensive cleanliness and maintenance problems at the location, such as dirty entryways and floors, damaged doors and trim, cobwebs, dusty fixtures, and several repair needs.
02 Nov 2023
02 Nov 2023
Confirmed staff are not following proper food storage procedures and are not maintaining the facility in a clean and sanitary condition.
26 Oct 2023
26 Oct 2023
Investigated the allegation that safe, healthful accommodations were not provided. Found that the original air conditioning unit in a resident's apartment stopped working after they moved in, a temporary unit was placed in the room, and no permanent repair had been completed by late October 2023.
§ 87303(a)
26 Oct 2023
26 Oct 2023
Confirmed failure to provide a working air conditioning unit for a resident in care.
§ 87303(a)
§ 87555(b)(9)
16 Oct 2023
16 Oct 2023
Investigated complaints about a resident’s needs, transportation safety, dignity, and reporting concerns. Found that staff did not provide wheelchair transportation during a temporary mobility change, bandage changes were to be done by home health, there was no evidence of a sign restricting complaints, and residents may report concerns to the ombudsman.
16 Oct 2023
16 Oct 2023
Found no evidence that staff failed to meet the resident's needs, kept the apartment unsanitary, or served meals contrary to dietary restrictions; the resident refused many offered aids, though staff made attempts to help and notified a responsible party. A technical violation was issued to ensure special diet needs are properly communicated and posted in the kitchen.
16 Oct 2023
16 Oct 2023
Confirmed staff attempted to assist a resident with self-neglect concerns, including showering and hygiene, but the resident refused. Identified lack of communication regarding resident dietary restrictions, leading to potential issues with meal service.
12 Oct 2023
12 Oct 2023
Found that a resident with SSI was charged beyond the basic rate for services. Found also that overnight staffing sometimes consisted of only one caregiver, not meeting the promised two-staff requirement.
§ 87464(e)
§ 87411(a)
12 Oct 2023
12 Oct 2023
Confirmed insufficient staffing and unjustified additional charges for a resident receiving SSI.
§ 87465(a)(4)
06 Oct 2023
06 Oct 2023
Investigated allegation that a staff member financially abused a resident by cashing a $2,000 donation intended for a resident-organized Christmas Fund and spending it on staff appreciation. Found that the check was cashed by the former administrator and used for staff events, but receipts for all charges could not be produced and there was no conclusive proof of misuse; the money was credited back to the resident's account, the former administrator no longer worked there, and no police report was filed.
06 Oct 2023
06 Oct 2023
Found AM shift staffing was sometimes below the planned level, with two caregivers on some days, though staff generally responded to calls within 10 to 16 minutes. Found during the 6/1/23 incident, staff and others assessed the resident after a fall, provided ice, and acted based on the resident’s report and subsequent checks, with no hospital transport.
06 Oct 2023
06 Oct 2023
Investigated the allegation that staff do not provide appropriate nutritional contents for residents; found that R1’s low-carb diet was documented and meals included adequate protein and carbohydrates, though R1 asked for more low-carb options.
Found no evidence that staff did not meet the resident’s diabetic needs; insulin orders and glucose monitoring were in place, but exact timing wasn’t documented, and there was no proof that delays contributed to the fall or fainting.
06 Oct 2023
06 Oct 2023
Found that staff did not ensure a resident with diabetes was fed timely, with breakfast delays in October 2022 due to only one server and orders calling for earlier service. Evidence showed that by January 2023 the resident was usually served first, resulting in shorter wait times.
§ 87555(b)(7)
06 Oct 2023
06 Oct 2023
Identified unsanitary kitchen conditions, including dirty floors with scattered food debris, stains, dirty dishes with flies, and an open screen door. Identified improper food handling and storage, with open or unlabeled foods in refrigeration and storage areas, spoiled items, and sugar stored with the lid off.
§ 87555(b)(27)
§ 87555(b)(9)
06 Oct 2023
06 Oct 2023
Confirmed unsanitary conditions in the kitchen and improper food handling and storage practices.
§ 87464(a)
13 Jul 2023
13 Jul 2023
Investigated the allegation that there were not enough nonperishable foods for a week; found extensive nonperishable items in the kitchen and in two storage units, and that several staff were unaware of where the backup emergency supplies were located.
13 Jul 2023
13 Jul 2023
Reviewed complaint alleging lack of emergency food supplies. Found an adequate stock of nonperishable food items in the kitchen and storage units, advising the purchase of additional supplies to accommodate special dietary needs and ensuring staff awareness of locations.
21 Jun 2023
21 Jun 2023
Found staffing improved with adequate coverage and residents satisfied, but End of Shift Reports showed inconsistencies in documenting completed versus incomplete tasks, with some entries missing reasons. Found the Manager on Duty calendar was not labeled and not posted in all departments, and it lacked full names and phone numbers.
21 Jun 2023
21 Jun 2023
Reviewed staffing and documentation procedures; noted inconsistencies in task completion reporting and lack of clarity in manager on duty schedule postings.
§ 87203
12 Apr 2023
12 Apr 2023
Found that staff mismanaged a resident’s medications, including three missed doses in July 2022 due to delays in refilling an oxycodone PRN and gaps in refill communication.
§ 87465(a)(4)
12 Apr 2023
12 Apr 2023
Confirmed mismanagement of resident medications, resulting in a substantiated allegation.
17 Mar 2023
17 Mar 2023
Investigated the allegation that staff mismanaged resident medications after pills fell on the ground; found the incident appeared to be an accident and replacement medications were provided within about 1 to 1.5 hours.
22 Mar 2023
22 Mar 2023
Investigated concerns about medication administration, dietary adherence, staff conduct toward a resident, and floor cleanliness at a care home. Found issues with how medications were recorded and given, deviations from dietary orders, inappropriate remarks by staff, and visibly worn carpets requiring attention.
22 Mar 2023
22 Mar 2023
Found that the allegation that staff disclosed a resident's confidential information in the presence of others was not supported based on interviews. Staff indicated they use room numbers rather than names on walkie-talkies to protect privacy, and leadership noted ongoing reminders about resident privacy.
22 Mar 2023
22 Mar 2023
Confirmed allegations of medication mismanagement, dietary needs not being followed, inappropriate staff behavior, and unsanitary conditions during the visit.
17 Mar 2023
17 Mar 2023
Identified that the allegation—residents not being provided their medications as prescribed—related to 1/1/23 and was tied to staffing shortages causing delays in AM doses. Found discrepancies between the medication administration records and the controlled drug record, with several doses either unrecorded or inconsistently documented.
§ 87465(a)(4)
17 Mar 2023
17 Mar 2023
Identified that staff tried to refill the resident’s pain medication on time, but delays caused by the doctor’s vacation and pharmacy/insurance issues led to the resident going without the medication for about three days.
17 Mar 2023
17 Mar 2023
Confirmed mishandling of a resident's medication but found that the facility's staff requested a timely refill, which was delayed due to the doctor's absence and insurance issues, resulting in the resident going without medication for a few days.
09 Mar 2023
09 Mar 2023
Identified a lapse in following dietary needs when a resident with a pepper allergy was served Cajun-seasoned fish. The allergy was not listed on the dietary needs record, and staff forgot the allergy despite the resident stating they could not eat pepper.
§ 87555(b)(9)
09 Mar 2023
09 Mar 2023
Found that on 3/4/2023 there was a period of about six hours with no caregiving staff present due to no response from the on-duty supervisor, and during that time some residents needed medication and toileting assistance but did not receive it. Found also that food service was generally adequate with milk and fruit available, though the dietary list did not specify dairy needs and some perishable items were noted.
§ 87411(a)
09 Mar 2023
09 Mar 2023
Confirmed lack of staff present in facility for over 5 hours, and improper provision of food service.
01 Mar 2023
01 Mar 2023
Found inadequate staffing at the site, with cooks and servers often unavailable and no driver to transport residents, causing long waits for meals and some meals arriving cold. Identified disrepair across the site, including nonfunctional third-floor washers, an out-of-service laundry room, two broken ovens (one later replaced to leave one working), dirty patio furniture, a missing gate latch on a pedestrian gate, and a damaged front parking pillar.
§ 87303(a)
§ 87411(a)
01 Mar 2023
01 Mar 2023
Identified the allegation of inadequate staffing, noting residents waited long times for meals due to missing cooks and limited dining staff. Staff covered multiple roles, meals sometimes arrived late or cold, and there were days without a driver to transport residents.
01 Mar 2023
01 Mar 2023
Found that the allegation that staff failed to administer residents’ medication as prescribed during the holidays was true, with several medications not given as prescribed on multiple dates due to staffing shortages. Found the allegation of inadequate food service not supported, as meals were generally adequate and inventories were maintained.
§ 87465(a)(4)
01 Mar 2023
01 Mar 2023
Identified improper food storage, medication administration lapses, infection control concerns, and dirty carpeting based on observations and interviews conducted in January and February 2023.
§ 87465(a)(1)
§ 87555(a)(9)
§ 87468.1(b)(2)
§ 87468.1(a)
01 Mar 2023
01 Mar 2023
Confirmed improper food handling and storage, mishandling of residents' medications, failure to follow infection control procedures, and inadequate facility maintenance.
§ 87411(a)
11 Jan 2023
11 Jan 2023
Identified insufficient staffing to meet residents’ needs as the issue, with evidence showing showers were delayed or missed and other care tasks were unmet due to staff shortages.
§ 87468.1(a)(2)
27 Jan 2023
27 Jan 2023
Found improper storage of food after residents reported ice cream was unavailable; a kitchen check showed an uncovered three-gallon ice cream container in the freezer and an uncovered bowl of salad in the refrigerator.
27 Jan 2023
27 Jan 2023
Found that staff did not wear face coverings while providing care and supervision to residents in the dining room.
§ 87468.1
27 Jan 2023
27 Jan 2023
Confirmed that a wrong medication was given to a resident on 9/16/22, discovered at 12:00 pm when the med-tech observed dizziness and fatigue and emergency personnel were called for low blood pressure. Reviewed on 1/26/23 after the 9/20/22 self-report, resulting in a deficiency and a civil penalty.
27 Jan 2023
27 Jan 2023
Identified incident where wrong medication given to resident, resulting in low blood pressure. Deficiency cited.
19 Jan 2023
19 Jan 2023
Identified inadequate medication training for staff, with meds distributed by an untrained staff member. Noted staffing shortages leading to late medication deliveries and care challenges; found no evidence that pills were mishandled or improperly stored.
§ 87468.1(a)(2)
§ 1569.69(a)(1)
19 Jan 2023
19 Jan 2023
Found that two staff tested positive for COVID-19 on 1/12/23 and 1/14/23, and the site did not report these cases to the Department within 24 hours; staff and the administrator were unaware of the reporting requirement. Identified two residents who tested positive on 1/7/23 and 1/10/23 and were not reported to the Department.
19 Jan 2023
19 Jan 2023
- Staff at the facility did not report positive COVID-19 cases among employees and residents to the appropriate agency within the required timeframe.
§
11 Jan 2023
11 Jan 2023
Investigated the allegation of improper storage of food items after observing unlabeled containers in the refrigerator; the Food Services Director admitted labeling should have been done.
11 Jan 2023
11 Jan 2023
Found improper food storage practices; food items in the refrigerator lacked labeling to indicate when they were stored.
§ 87211(a)(2)
03 Jan 2023
03 Jan 2023
Found multiple issues: missing infection control signage at entry and throughout; a round table leaning into a hallway blocked a fire exit; staff not wearing masks properly; and unsafe food storage with moldy strawberries and cucumbers, an uncovered ice cream container, and a torn tortilla bag.
03 Jan 2023
03 Jan 2023
Identified deficiencies in infection control practices, fire safety, staff mask-wearing, and food storage during the inspection.
§ 87555
10 Nov 2022
10 Nov 2022
Investigated a sexual abuse allegation involving a staff member and a resident; the staff member admitted taking the resident for a drive, kissing the resident, and touching the resident's buttocks and breast. Found sufficient evidence to support the allegation.
10 Nov 2022
10 Nov 2022
Confirmed that a staff member sexually abused a resident.
07 Sept 2022
07 Sept 2022
Found improper food handling and storage techniques, including unlabeled and spoiled items in the kitchen. Found designated substitutes on site during the administrator's absence.
§ 87555(b)(9)
07 Sept 2022
07 Sept 2022
Confirmed improper food handling and storage techniques and unsubstantiated absence of on-site administrator.
§ 87303(a)
§ 87465(a)(4)
§ 87468.1(a)(1)
30 Aug 2022
30 Aug 2022
Identified extensive issues and 20 complaints since licensure, including staffing shortages, an unsafe environment, medication and food service problems, fingerprint clearance delays, unlawful rate increases, eviction, transportation challenges, COVID-19 protocol issues, and physical plant concerns. Noted leadership changes with a new executive director expected soon.
30 Aug 2022
30 Aug 2022
Identified multiple complaints and deficiencies at the facility, including staffing, safety, medication, food services, and COVID-19 protocols.
§ 87202(a)
§ 87555
§ 87468.1
15 Jul 2022
15 Jul 2022
Found insufficient staffing to meet resident needs, particularly in dining services, caregiving, and medication dispensing. Found staff not adequately trained to monitor medical conditions, noted a resident requiring a higher level of care was retained without proper re-evaluation or eviction, and found concerns about inadequate food though several residents reported satisfactory quantity and quality.
§ 87411(a)
15 Jul 2022
15 Jul 2022
Identified that the resident was evicted the same day as the notice without proper procedures, including no 30-day written notice, no reappraisal, no update to the care plan, and no physician consultation; the family was contacted to facilitate the eviction, and the resident moved out within a few days.
§ 87224(a)(4)
15 Jul 2022
15 Jul 2022
Confirmed insufficient staffing levels, found no evidence of inadequate staff training, and could not verify claims of resident retention issues or inadequate food.
§
12 Jul 2022
12 Jul 2022
Investigated the allegation that residents were not provided transportation to medical appointments. Found that transportation was not consistently provided, with staff indicating residents had to arrange their own rides or rely on others.
§ 87465(a)(2)
12 Jul 2022
12 Jul 2022
Confirmed lack of transportation for residents to medical appointments.
30 Jun 2022
30 Jun 2022
Found the allegation that staff left rags with hazardous chemicals in the kitchen causing a chemical reaction to be unsubstantiated, with interviews indicating no hazardous situation or danger to residents.
30 Jun 2022
30 Jun 2022
Found no evidence of insolvency; residents' basic needs were met, and vendors were ultimately paid. However, there were multiple late payments to utilities and food invoices in 2021, resulting in a technical violation.
30 Jun 2022
30 Jun 2022
Found that staff responded promptly to residents' call buttons and that living areas appeared clean, based on interviews and a tour.
30 Jun 2022
30 Jun 2022
Found no evidence of hazardous chemicals causing a chemical reaction in the kitchen as alleged, with interviews indicating no danger to residents.
09 Jun 2022
09 Jun 2022
Found that staff did not wear face coverings, posing a health risk to residents. A civil penalty was issued.
09 Jun 2022
09 Jun 2022
Found insufficient staffing to meet residents' needs, with evidence of a low staff-to-resident ratio, delays in meals and medications, and limited housekeeping coverage.
09 Jun 2022
09 Jun 2022
Found failure to ensure staff were wearing face coverings, posing a risk to residents' health and safety.
§ 87411(a)
07 Jun 2022
07 Jun 2022
Investigated the allegation that staff did not follow COVID-19 protocols; found that masks were worn improperly during interactions with residents.
07 Jun 2022
07 Jun 2022
Confirmed that staff did not follow COVID-19 protocols regarding face mask usage while interacting with residents.
28 May 2022
28 May 2022
Identified that staff failed to wear face coverings properly while caring for residents, with masks worn below the nose and a close, face-to-face interaction observed.
§ 87468.1
28 May 2022
28 May 2022
Found staff not wearing masks properly while interacting with residents, including not maintaining proper social distance or wearing masks over their noses and mouths.
§ 87555(b)(9)
10 May 2022
10 May 2022
Identified that two staff members were not associated with the site during their community work; one was not listed in the agency system for the relevant dates, and the other did not become associated until after those dates. Imposed civil penalties totaling $1,500 and conducted an exit interview.
§ 87355(e)(2)
10 May 2022
10 May 2022
Investigated allegation that a staff member sexually abused a resident; the resident reported it to staff on 5/07/22, interviews with the administrator and staff were conducted, and further investigation was needed.
10 May 2022
10 May 2022
Investigated allegations of abuse reported by a resident and staff member.
06 May 2022
06 May 2022
Found that the home did not have a permanent administrator for an extended period. Residents reported little management presence, and incident reports increased during that time.
§ 87405(a)
06 May 2022
06 May 2022
Investigated allegation that staff failed to assist residents in self-administration of medication, finding that three residents did not receive medications on time during the night shift.
§ 87465(a)(4)
06 May 2022
06 May 2022
Confirmed lack of administrator at the _____________, leading to increased resident incidents and lack of support from management.
§ 87468.1
04 May 2022
04 May 2022
Identified ongoing safety concerns with the garage-to-building door, which is heavy, self-closing, and difficult for residents using walkers, despite staff efforts to fix it.
Found no documentation of injuries to any resident from using the door, and wellness and incident records contained no evidence of harm.
04 May 2022
04 May 2022
Found that the allegation that the environment was not safe for residents in care due to power outages and insufficient lighting in a resident’s room during construction below the room was supported. Noted outages occurred over several days in December 2021, staff provided a lamp and extension cord, and by the end of December power and lighting were restored.
04 May 2022
04 May 2022
Confirmed safety concern due to multiple instances of power outages in a resident's room, resulting in insufficient lighting for over 24 hours.
20 Apr 2022
20 Apr 2022
Found no evidence of mismanaging residents’ medications, as residents reported receiving all prescribed meds on time. Found residents were provided activities with a designated activities lead, and kitchen observations showed proper food storage with prep occurring on counters for immediate cooking.
20 Apr 2022
20 Apr 2022
Investigated allegations of medication mismanagement, lack of activities, and improper food storage. Medication delivery and timing found satisfactory, activities provided regularly, and food properly stored.
§ 87303(d)
30 Mar 2022
30 Mar 2022
Investigated findings showed that transportation for medical appointments was restricted to Tuesdays and Thursdays with limited hours, creating difficulties for residents to obtain rides. Found that transportation was not arranged as needed for residents, leaving them without essential transportation.
§ 87465(a)(2)
30 Mar 2022
30 Mar 2022
Investigated the allegation that transportation for residents was not arranged; found that transportation hours were reduced to Tuesdays and Thursdays, limiting access to medical appointments.
Investigated the allegation that kitchen storage, cleanliness, and repair did not meet standards; found issues such as open food containers, dirty surfaces, and improper temperatures.
30 Mar 2022
30 Mar 2022
Confirmed lack of transportation provided for medical appointments to residents on specific days and times as per previous policy.
§ 87303(a)
23 Mar 2022
23 Mar 2022
Identified that a resident was injured during a staff-assisted wheelchair incident, suffering a broken nose, a broken finger, and a facial fracture. Found that the injuries occurred while under staff supervision, and an immediate civil penalty of $1,000 was issued.
§ 87468.2(a)(4)
23 Mar 2022
23 Mar 2022
Found that invalid rate increases were applied to monthly care fees and residents were not timely notified in writing; civil penalties were issued for 15 days at $100 per day and will continue to accrue until the issue is addressed.
23 Mar 2022
23 Mar 2022
Confirmed injuries sustained by a resident due to staff negligence, resulting in a civil penalty being assessed.
§ 87465(a)(2)
§ 87555(b)(9)
08 Mar 2022
08 Mar 2022
Found that the allegation that residents were given illegal rate increases was supported. The 02/15/22 rate-change letters were deemed invalid because increases were not tied to a higher level of care or a base-rate change, and pricing for services was not properly updated.
08 Mar 2022
08 Mar 2022
Identified illegal rate increase for residents due to lack of evidence for higher level of care provided. Civil penalty imposed for repeat violation.
01 Mar 2022
01 Mar 2022
Found insufficient evidence to support the allegation that the resident’s grooming needs were not met while in care.
01 Mar 2022
01 Mar 2022
Found that a staff member’s actions in assisting a resident caused a fall and an injury, and that the resident’s room was not properly maintained. A $500 immediate civil penalty was assessed.
01 Mar 2022
01 Mar 2022
Confirmed a staff member caused injury to a resident and that the resident's room was not properly maintained.
§ 1569.655(a)
18 Feb 2022
18 Feb 2022
Found entry screening with hand sanitizer available and staff and residents wearing masks; bathrooms in common areas lacked handwashing reminder signage, and a double gate near the garden needed repair with an automatic closing mechanism. Confirmed fire extinguishers were in compliance and recently tested; no deficiencies were noted during the infection control mitigation module.
18 Feb 2022
18 Feb 2022
Confirmed observations of staff following COVID protocols, presence of hand sanitizing stations, lack of handwashing reminder signage in common area bathrooms, and need for repair of garden gate.
08 Jul 2021
08 Jul 2021
Investigated the complaint that the dining room was not kept at a comfortable temperature. Dining room temperatures were generally at or above 68 F, with readings around 68-74 F and space heaters in use, and residents reported no overall discomfort.
08 Sept 2021
08 Sept 2021
Identified that R1 did not receive clean linens and the room was not kept clean or sanitary. Determined that rent increases were limited to the allowed 3% annually, with no $1,500 increase.
08 Sept 2021
08 Sept 2021
Found that 60 days' prior written notice of rent increases to residents was not provided as required. Ledgers showed rent increases not credited for several residents after they moved out, many notification letters remained unsigned, and refunds were still due.
08 Sept 2021
08 Sept 2021
Confirmed that staff did not provide clean linens and that resident's room was unsanitary. The allegation of staff increasing resident's rate was determined to be unsubstantiated.
26 Aug 2021
26 Aug 2021
Found that not all current and former residents received the required 60-day written notice and credits for the 2021 rent increase. Also identified that several former residents had not yet received credits, and one resident's ledger contained errors showing charges despite a rent freeze.
26 Aug 2021
26 Aug 2021
Identified deficiencies in notifying residents of rent increases and crediting accounts for rental increases, with some residents not receiving proper adjustments or credits as required.
§ 87307(a)(3)
§ 87303(a)
12 Aug 2021
12 Aug 2021
Found two staffing issues at the site: one worker was fingerprint cleared but not associated and had been on duty since July 4, told not to report until associated; the other worker was on site without clearance and had been working since March 11, instructed to leave until clearance. Penalties totaling $1,500 were assessed for two deficiencies; an exit interview was conducted and appeal rights provided.
12 Aug 2021
12 Aug 2021
Identified deficiencies in staff background checks resulted in civil penalties being assessed.
08 Jul 2021
08 Jul 2021
Investigated the allegation of an uncomfortable temperature in the dining room; found that the room was kept within a comfortable temperature range, with temperatures recorded between 68°F and 74°F, supported by space heaters.
§ 87468.2(a)(4)
§ 87303(a)(1)
01 Jul 2021
01 Jul 2021
Found that rent increases were implemented without the required 60-day written notice to residents. Residents did not receive the 10/25/2020 notice and were told in 1/2021 that the increase would take effect 3/01/2021, providing only about 34 days’ notice.
§ 1569.655(a)
01 Jul 2021
01 Jul 2021
Confirmed that the facility increased rental rates without proper notice to residents.
30 Apr 2021
30 Apr 2021
Found that an initial report of a staff member not wearing a mask was not observed during a video visit, as all staff wore face coverings; masks were noted to be lowered briefly to communicate with a hard-of-hearing coworker.
30 Apr 2021
30 Apr 2021
Confirmed staff were observed wearing face coverings during the visit, following a report of a staff member not wearing a mask.
§ 1569.655(a)
14 Oct 2020
14 Oct 2020
Investigated various complaints regarding the HVAC system, food service, record keeping, overcharging residents, and staffing levels. Issues with HVAC system and record keeping were identified, while allegations of inadequate food service, overcharging residents, and insufficient staff were not substantiated.
14 May 2020
14 May 2020
Investigated allegations of an unsafe and unsanitary environment, lack of supervision leading to falls, and inadequate staffing. Determined all claims were unsubstantiated, with no evidence supporting any failure in providing care or supervision.
13 Feb 2020
13 Feb 2020
Found high water temperatures in common area bathrooms and missing emergency evacuation chairs in stairwells during a complaint visit.
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§
09 Jan 2020
09 Jan 2020
Confirmed cleanliness and proper functioning of physical plant, resident rooms, kitchen, and storage areas during pre-licensing visit.
§ 87355(e)(2)
§ 87355(e)(1)
19 Dec 2019
19 Dec 2019
Confirmed successful completion of COMP II by the applicant/administrator during a telephone call with the analyst at CAB, with understanding demonstrated in various areas related to facility operation and compliance with regulations.
04 Oct 2019
04 Oct 2019
Identified deficiency during visit, new administrator appointed.
