306005326-11-24-2021-22-AS-MVAO-CBBSX9-20220204131531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005326
Report Date: 11/24/2021
Date Signed: 11/24/2021 11:45:06 AM

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
07/22/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200722134130

FACILITY NAME:	CRESTAVILLA SENIOR LIVING		FACILITY NUMBER:	306005326
ADMINISTRATOR:	KEYS, BRIAN		FACILITY TYPE:	740
ADDRESS:	30111 NIGUEL RD		TELEPHONE:	(949) 345-1606
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	250	CENSUS: 157	DATE:	11/24/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Brian Keys		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff failed to ensure residents eating needs are being met while in care.

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings in regards to the complaint investigation for the allegation, Staff failed to ensure resident's eating needs are being met while in care. LPA was screened for Covid-19 and granted entry. LPA met with Executive Director Brian Keys. LPA explainted the reason for the visit. The investigation revealed the following; Resident 1 (R1) moved into the facility on 8/24/2018. R1 moved out of the facility on 7/31/2020. After a review of R1’s physician’s report (LIC 602A), admission agreement, pre-appraisal and care plan it has been determined that R1 was not receiving any extra services beyond basic care. It was noted on the R1’s physician report and pre-appraisal that R1 did not require or request any assistance with eating. R1’s needs and service plan did not list eating as an item R1 required assistance with. It was reported that the facility staff did not provide any assistance with R1 regarding eating. Interview of staff and review of facility policy show the facility does not offer any type of feeding service (staff directly feeding resident) for residents. The Administrator and Resident Services director reported that they did speak to the responsible party (RP) for R1 about R1’s eating habits and the role and responsibility of the facility regarding assisting R1, Continued on LIC 9099 C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200722134130

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: 11/24/2021

NARRATIVE

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Continued from LIC 9099, and the RP did not provide any guidance on how they wanted to proceed in regard to assisting R1 even though the Administrator informed RP that they could hire a care companion to feed or assist the client beyond the services provided by the facility, because the facility does not feed the residents directly and does not have staff sit with the resident during meal time to continually encourage eating during meal time. RP for R1 verified this information. Staff interviewed, reported that they encourage all residents to eat and bring the food to residents whether it is in the dining room or the resident’s room. It was reported that R1 did not eat for 2 days. Even though staff reported that R1’s food intake was decreasing no one interviewed could corroborate that R1 did not eat for 2 days. R1’s spouse had recently passed away and R1 was on hospice, staff interviewed and R1’s RP corroborated this information. All parties interviewed agreed that food was provided to R1 and that staff did ask R1 to eat but they did not sit with R1 while they ate and did not feed R1 directly. Based on the evidence gathered through interviews and records review the allegation, staff failed to ensure residents eating needs are being met while in care, are 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. An exit interview was conducted, and a copy of the report provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC9099 (FAS) - (06/04)

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