306005326-3-16-2023-22-AS-LADS-CPZTS6-20230317145837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005326
Report Date: 03/16/2023
Date Signed: 03/16/2023 10:24:44 AM

Unfounded

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
11/18/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201118133037

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: 160	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rafael Salmeron		TIME COMPLETED:	10:42 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to reassess resident for appropriate level of care.
Facility does not have fall prevention plan in place.
Facility does not give medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for complaint investigation into the allegations listed above. LPA met with Housekeeping Supervisor Rafael Salmeron. The investigation into the allegation, facility failed to reassess resident for appropriate level of care, revealed the following. It was alleged that after Resident 1 (R1) suffered an unwitnessed fall on 11/10/22 and was taken to the hospital the facility did not reassess R1 and has not addressed their possible need for a higher level of care. The Executive Director and facility staff member interviewed reported that R1 has another doctor’s appointment scheduled to be reassessed by their physician on 12/2/20, once R1 has been reassessed by their medical professional the facility will conduct their assessment and meet with R1 and their family to discuss a new needs and service plan if required. R1 and their family verified this report. The facility staff reported that the family of R1 never provided the documentation from R1's appointment in December. The facility conducted an assessment of R1 on 12/9/20. The assessment shows R1 did not need a higher level of care and there were measures in place to address his needs concerning mobility. As of 11/21/20 resident has a care companion to assist with mobility and help mitigate R1's fall risk.

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: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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 22-AS-20201118133037

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: 03/16/2023

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

Based on the evidence gathered through interviews and a record review, the allegation, facility failed to reassess resident for appropriate level of care is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

The investigation into the allegation, facility does not have fall prevention plan in place, revealed the following: R1 has fallen 3 times from 10/25/20 to 11/10/20. The needs and service plan of R1 dated 8/12/20 shows R1 as a fall risk. The facility plan shows that R1 will be checked 3 times a day, encouraged to use his walker and the safety of his equipment (walker and scooter) checked twice a day. R1 and staff both reported that R1 is checked on at least 3 times a day. The Executive Director reported that the family of R1 was informed that R1 should have a care companion to mitigate the risk of falling. The family of R1 agreed and has arranged for a care companion beginning 11/21/20. R1 verified that they now have a care companion. Facility staff, R1 and the family of R1 reported that R1 has increased checks in the evening when the care companion has left for the day. Based on the evidence gathered through a review of documents and interviews the allegation facility does not have fall prevention plan in place is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

The investigation into the allegation, facility does not give medication as prescribed, revealed the following: R1 is currently managing his own medication. R1’s physician’s report dated 7/20/18 states R1 can manage his own medication. R1 has not been noted with a change in condition and has not been diagnosed with Dementia, so an updated physician’s report is not required at this time. R1, staff and R1’s family have not reported any issues regarding R1’s medication. At this time R1 is allowed to manage their own medication. R1 was reassessed by the facility on 12/9/20 and it was determined that they have not had a change in condition and could still manage their own medication. R1 and their family did not provide the facility any documentation from R1's doctors' appointment on 12/2/20. R1 moved out of the facility in March of 2021. LPA could not make contact with R1 or their family after March 2021. Based on the evidence gathered through a document review and interviews the allegation, facility does not give medication as prescribed is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. 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: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2