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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801971
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:22:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240105150509
FACILITY NAME:PASO ROBLES SENIOR LIVINGFACILITY NUMBER:
405801971
ADMINISTRATOR:ERIC BUNTEFACILITY TYPE:
740
ADDRESS:380 SCOTT STREETTELEPHONE:
(805) 227-4383
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Eric Bunte - LicenseeTIME COMPLETED:
02:18 PM
ALLEGATION(S):
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Cleaning supplies were accessible to residents in care.
Knives were accessible to residents in care.


INVESTIGATION FINDINGS:
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 At 8:01am on 01/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct the initial investigation to this complaint. LPA met with Licensee Eric Bunte announced who he is and the reason for the visit.
LPA conducted a facility tour, conducted interviews, collected documents, made observations, and took photographs. LPA was able to make finial finding determinations based on the initial investigation visit as outlined below:
As to the allegation of, “Cleaning supplies were accessible to residents in care.” It was alleged by a reliable source that cleaning supplies, knives, and medications were accessible to residents in care in the first week of January 2024. On 01/09/2024, LPA Jeffries conducted an unannounced investigation visit to the facility where he observed and photographed a plastic bin of approximately 30 ounces of powdered detergent with no lid, and a large (40-60 oz. approximately) fabric softener bottle on top of the dryer.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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 5
Control Number 29-AS-20240105150509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PASO ROBLES SENIOR LIVING
FACILITY NUMBER: 405801971
VISIT DATE: 01/09/2024
NARRATIVE
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 The facilities washer and dryer are in an open hallway closet with no door and a curtain that was slid open during the investigation visit. The washer and dryer are in direct access of entering and exiting 3 resident rooms in this facility. LPA interviewed Staff 1 (S1), who stated, “that’s where we have been keeping the detergent.” when asked by LPA. LPA instructed S1 to secure the detergent and fabric softener so that it was not accessible to resident in care. LPA noted that there is currently a resident in care that has a diagnosis of dementia which regulations require these items to be inaccessible. Items reported, and observed were accessible to residents in care. At this time there is enough evidence to support the allegation of, “Cleaning supplies were accessible to residents in care.” and is substantiated at this time.
As to the allegation of, “Knives were accessible to residents in care.” It was alleged by a reliable source that cleaning supplies, knives, and medications were accessible to residents in care in the first week of January 2024. On 01/09/2024, LPA Jeffries conducted an unannounced investigation visit to the facility where he observed and photographed 3 large kitchen knives, and scissors in an open drawer in the kitchen. LPA interviewed staff 2 (S2) about the knifes, and scissors in the open drawer and S2 stated, we don’t use those knifes.” and “they have been there.” LPA noted that the drawer LPA found the knifes, and scissors was the first drawer as you would enter the kitchen and was not a secured drawer. LPA photographed the knifes and scissors in the unsecured drawer and asked S2 to secure them in the secure lockable knife drawer located adjacent to the unsecured drawer in the kitchen. LPA noted that there is currently a resident in care that has a diagnosis of dementia which regulations require these items to be inaccessible. Items reported, and observed were accessible to residents in care. Based on observations, interviews, and photographic evidence there is enough evidence to substantiate the allegation of, “Knives were accessible to residents in care.” and is substantiated at this time.


Exit interview, report read, citations issued, appeal rights and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240105150509

FACILITY NAME:PASO ROBLES SENIOR LIVINGFACILITY NUMBER:
405801971
ADMINISTRATOR:ERIC BUNTEFACILITY TYPE:
740
ADDRESS:380 SCOTT STREETTELEPHONE:
(805) 227-4383
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Eric Bunte - LicenseeTIME COMPLETED:
02:18 PM
ALLEGATION(S):
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Medications were accessible to residents in care.
Facility did not have an adequate amount of fruit.
INVESTIGATION FINDINGS:
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 At 8:01am on 01/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct the initial investigation to this complaint. LPA met with Licensee Eric Bunte announced who he is and the reason for the visit.
LPA conducted a facility tour, conducted interviews, collected documents, made observations, and took photographs. LPA was able to make finial finding determinations based on the initial investigation visit as outlined below:
As to the allegation of, “Medications were accessible to residents in care.” It was alleged by a reliable source that cleaning supplies, knives, and medications were accessible to residents in care in the first week of January 2024. On 01/09/2024, LPA Jeffries conducted an unannounced investigation visit to the facility where he observed medication closet of the facility which was located in the hallway entrance of the facility and was locked by a gold and silver key padlock. LPA observed S2 unlock the medication closet during the morning medication pass on the initial investigation visit on 01/09/2024.
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240105150509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PASO ROBLES SENIOR LIVING
FACILITY NUMBER: 405801971
VISIT DATE: 01/09/2024
NARRATIVE
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LPA noted that once S2 secured the medications for the A.M. medication pass, S2 then secured the medication closet by locking the keyed padlock before administering medications. LPA noted that during the investigation visit that the medications were not accessible to residents in care at any time. LPA interviewed 3 of 5 Residents. R1-3 all stated that they had no issues with medications, food, and felt safe in this facility. LPA interviewed Staff 1 and 2. S1 and S2 both stated that the medication closet is locked unless they are working on administering medications. At this time there is not enough evidence to support the allegation of, “Medications were accessible to residents in care.” and is unsubstantiated at this time.
As to the allegation of, “Facility did not have an adequate amount of fruit.” It was alleged by a reliable source that there was limited to no fruit and molded fruit on hand for the residents in care in the first week of January 2024. On 01/09/2024. LPA conducted initial investigation visit and was able to observe approximately 2 ripe bananas, 3 pomegranates, 2 ripe kiwis, 12 oranges, and 4 apples, full stock of celery, and 6 cucumbers which is an acceptable amount of perishable foods for 5 residents, for two days. LPA noted that there are more than two dozen canned fruits and vegetables in the garage pantry that have been in stock for at least 3 months according to Licensee and S2. LPA did not observe any molded, spoiled or rotten food on hand in the facility during this investigative visit. LPA interviewed S2, who stated, “we always have more then enough food” and “we always have fresh fruits and vegetables for two days.”. S2 also stated that the facility has planned food shopping every two weeks and as needed. LPA interviewed Licensee who stated that, “we shop every two weeks, but if we need something we go out and buy it as its needed.” LPA interviewed Residents 1-3, R1-3 stated, that they had no issues with medications, food, and felt safe in this facility. Based on interviews, observations, and photographs there is not enough evidence at this time to substantiate the allegation of, “Facility did not have an adequate amount of fruit” and is unsubstantiated at this time.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240105150509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PASO ROBLES SENIOR LIVING
FACILITY NUMBER: 405801971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
Section Cited
CCR
87705(f)(1)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement was not met by evidence of knifes being accessible to residents in care.
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Licensee agrees to conduct 1 hour of training for all staff on care of residents with dementia, with focus on securing potentially dangerous times. This requirement must be started by 01/10/2024.
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which poesses and immidate threat to resident in care.
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Type A
01/10/2024
Section Cited
CCR
87705(f)(2)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Licensee agrees to conduct 1 hour of training for all staff on care of residents with dementia, with focus on sun downing behaviors for residents with dementia. This requirement must be started by 01/10/2024.
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This requirement was not met by detergent and fabric softener being accessible to resident with dementia, which posses in immediate threat to resident in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5