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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005326
Report Date: 06/12/2020
Date Signed: 06/15/2020 03:04:39 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200330164138
FACILITY NAME:CRESTAVILLA SENIOR LIVINGFACILITY NUMBER:
306005326
ADMINISTRATOR:KEYS, BRIANFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 345-1606
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 83DATE:
06/12/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Brian KeysTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not meeting the resident needs.
Staff would handle resident aggressively.


INVESTIGATION FINDINGS:
1
2
3
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5
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7
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9
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13
Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to deliver findings on a complaint investigation due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation with Executive Director Brian Keys. During the investigation, LPA Alejandre interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as medical records and facility schedules. Regarding the allegation; staff not meeting the resident needs, it was alleged that Resident 1 was not assisted timely with incontinence care. Staff reported that R1 is changed at least 3 times a day. Staff reported that R1 is changed at least once during each shift and checked throughout each shift in case of accidents. The Executive Director reported that all residents are supervised and checked throughout the day to ensure the residents are properly cared for and are comfortable. There was no evidence other than the complainant’s allegation that R1 did not receive assistance with incontinence care to support the allegation. Therefore, the allegation, staff not meeting the resident needs, is deemed to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
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 4
Control Number 22-AS-20200330164138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRESTAVILLA SENIOR LIVING
FACILITY NUMBER: 306005326
VISIT DATE: 06/12/2020
NARRATIVE
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In regard to the allegation; staff would handle resident aggressively, it was alleged that staff handled R1 roughly and aggressively when he was changed or cleaned. Staff reported that R1 was never handled inappropriately and was never handled in a rough or aggressive manner. Staff reported that all the residents are cared for in a safe manner. The Executive Director reported all residents are cared for in a safe responsible manner. Based on the interviews conducted the allegation, staff would handle resident aggressively, is deemed to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with the Executive Director Brian Keys via telephone and a copy of this report was provided to Executive Director Brian Keys via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200330164138

FACILITY NAME:CRESTAVILLA SENIOR LIVINGFACILITY NUMBER:
306005326
ADMINISTRATOR:KEYS, BRIANFACILITY TYPE:
740
ADDRESS:30111 NIGUEL RDTELEPHONE:
(949) 345-1606
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:250CENSUS: 83DATE:
06/12/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Brian KeysTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refusing to allow resident to have visitor(s).
INVESTIGATION FINDINGS:
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13
In regard to the allegation; staff refusing to allow resident to have visitor(s), it was alleged that a third party care provider was banned from the facility and not allowed to return. It was reported that third party care companion was at the facility for 3 separate visits. Staff reported that the third party care companion never returned after the last visit and were not notified to report on or to keep anyone out. Executive Director Keys reported he had spoken to the third party care companion about visiting the facility and proper procedures if there were issues but stated he did not ban anyone from the facility. Executive Director Keys stated no one has been banned from the facility. Executive Director Keys reported that any resident who requires a necessary visit at the facility or outside the facility would be accommodated. The visits which did take place were after the facility had been in compliance with the visitation restrictions put in place by Community Care Licensing. Staff reported that hospice visits have taken place during the lockdown. Based on the interviews conducted the allegation stated above is deemed unfounded, meaning the Department has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the allegation. Continued on LIC 9099C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20200330164138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CRESTAVILLA SENIOR LIVING
FACILITY NUMBER: 306005326
VISIT DATE: 06/12/2020
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
An exit interview was conducted with the Executive Director Brian Keys via telephone and a copy of this report was provided to Executive Director Brian Keys via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4