405800577-7-26-2023-29-AS-DCHZ-CU53DQ-20230726180954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 07/26/2023
Date Signed: 07/26/2023 06:11:05 PM

Document Has Been Signed on 07/26/2023 06:11 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:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 84		CENSUS: 68	DATE:	07/26/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Kirk Klotthor, Administrator		TIME COMPLETED:	06:25 PM

NARRATIVE

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On 7/26/23 at 11:39 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 7/14/23. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit.

Medications are centrally stored in a locked medication room. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medications show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current. In 2 out of 2 residents’ medications/bubble packs, medications (2) were set aside in advance for two days. Medications can only be stored in a separate dispenser within 24 hours of dispensing to resident. Technical violation issued. Administrator will conduct a training with all med-techs and send CCL the training sign-in sheet by 8/2/23.

Staff files: All required training has been completed.

On the Annual Inspection Report dated 7/14/23, the facility was cited for Staff #1 (S1) not being associated with the facility, however, the Deficiency Report (LIC 809-D) and Civil Penalty did not print. LPA is providing the LIC 809-D and civil penalty to the administrator at this time with a correction: The Annual Inspection Report (LIC 809) dated 7/14/23 states “S1 was not associated with the facility during their entire time working in the facility.” The correction is that S1 was employed in August 2021 and employment ended in July 2023. Licensing records indicate S1 was associated from August 2021 through June 2022, and not associated from June 2022 through July 2023.

Exit interview conducted, deficiency and civil penalty issued, and report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 07/26/2023 06:11 PM - It Cannot Be Edited

Created By: Darlene Chavez On 07/26/2023 at 05:34 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that S1 was employed and not associated to the facility from June 2022 through July 2023 which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator says S1 is no longer working in the facility as of July 2023. Administrator will write a statement of understanding of the regulation cited above to ensure future staff are associated to the facility and will send to CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

LICENSING EVALUATOR NAME:

Darlene Chavez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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