405850010-7-16-2021-29-AS-KBUY-C7HTYY-20211005150932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:11:40 AM

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
07/01/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210701150257

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR:	CHERYL MARSH		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	130	CENSUS: 78	DATE:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	07:55 AM
MET WITH:	Administrator/Cheryl Marsh		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff does not meet resident's toileting needs.

INVESTIGATION FINDINGS:

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At 8:35am, on 07/16/2021, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to issue final findings for the allegation listed above. LPA met with Administrator Cheryl Marsh and announced the reason for this visit.
As to the allegation of, “Staff does not meet resident's toileting needs”; LPA conducted complaint investigation at 9:30am on 07/08/2021, LPA observed and photographed ample incontinence products to meet the needs of the residents of a 130-bed facility. At 10:02am – 10:35am LPA physically observed residents’ rooms 126, 131, 132, and 138. Room 110 was occupied and declined entrance by resident due to visitation in progress in room 110, LPA noted no olfactory abnormalities in and outside of listed rooms. LPA conducted interviews with Residents, Staff and Administrator. LPA view staff schedules, incontinence product distribution logs, resident physician reports, Appraisal Needs and Services plans and staff training records. LPA noted that the schedule reflected enough staff to meet the toileting needs of residents in care and were properly trained to care for residents with incontinence needs as reflected by initial training records (Shadowing training and videos). CONTINUED on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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 29-AS-20210701150257

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: CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 405850010
	VISIT DATE: 07/16/2021

NARRATIVE

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LPA's Interviews of staff revealed one incident of soiled briefs of R1 which was soiled on the NOC to AM shift transfer the morning of 07/03/2021, however, R1 could not recall a time when their incontinence needs were not met. Through observation, records, training logs, interviews and photographic evidence it is determined at this time there is not enough evidence to support that allegation of, “Staff does not meet resident's toileting needs” therefore this allegation is unsubstantiated at this time.

Exit interview, report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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