306005326-12-27-2023-22-AS-SSAS-CZYRUA-20240130121937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005326
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:30:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
01/04/2022 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220104141530

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:	0	CENSUS: 0	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Sesh Sturhann, Assistant General Manager		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not following the proper protocol for COVID-19

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted by receptionist and granted entry. LPA spoke with Sesh Sturhann, Assistant General Manager and explained the purpose of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which include interviews conducted, tour of physical plant of facility and copy of pertinent documents obtained.

It is alleged facility is not following the proper protocol for COVID-19. Review of facility records revealed that the facility was following PIN 20-01-ASC dated March 13, 2020, and PIN 20-23-ASC dated June 26, 2020.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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-20220104141530

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESTAVILLA SENIOR LIVING	FACILITY NUMBER: 306005326
	VISIT DATE: 12/27/2023

NARRATIVE

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Per interview with Administrator revealed that the facility would send out notices to residents and families with any covid updates and protocol. Facility used an inhouse covid-19/infection control protocol grid that followed the local and state regulatory guidelines for COVID-19. The facility would also send out notices to residents when there were any positives reported in the facility to keep the residents updated. The facility also utilized an application where they would send out notices, news, and any updates to the residents. The tour of the physical plant of the facility conducted on January 13, 2022, LPA Martinez observed staff wearing masks, and all visitors and staff checked in with accushield that followed covid guidelines with temperature checks and a questioner. Interviews with 10 of 10 residents revealed that they received a notice on January 7 and January 8, 2022, pertaining to covid positives at the facility and information about vaccines/covid protocols at the facility. Interviews revealed that residents felt the facility kept them informed on any updates with covid, resident are asked/reminded to keep social distancing, and resident feel like the facility is doing their best to keep everyone safe from covid.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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