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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:30:16 PM



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
01/15/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210115105930
FACILITY NAME:CRESTON VILLAGE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:CYNTHIA EDWARDSFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:130CENSUS: 76DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sherry McCormick, Wellness DirectorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff member does not treat residents with dignity and respect
Staff member made inappropriate comments to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Wellsness Director Sherry Mccormick and explained the purpose of the visit.

LPA Jeffries conducted the initial investigation on 01/19/2021 from 10:48 AM to 2:00 PM with interviews and documentation collection.

LPA De Leon conducted staff interviews on 03/10/2021 at 1:00 PM, 1:16 PM, 1:30 PM, 3:45 PM, 4:00 PM, 4:20 PM, 4:48 PM, 5:20 PM and resident interviews at 2:00 PM, 2:22 PM, 2:31 PM, 2:39 PM, 2:52 PM, 3:18 PM, 3:33 PM. LPA requested additional documentation on 03/11/2022 at 12:00 PM. LPA reviewed documentation at 12:45 PM on 03/11/2022.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
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 3
Control Number 29-AS-20210115105930
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: 03/11/2022
NARRATIVE
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On the allegation: Staff Member does not treat residents with dignity and respect. LPA interviews with staff revealed that there were some staff back in 2020-2021 that spoke in a demeaning way to residents in care, some staff were terminated or left for those reasons, and all current staff is interacting well with the residents and no one in 2022 has heard any other complaints from residents about interaction with staff. The facility did an internal investigation due to this complaint and found that R1 and S1 had had a conversation were the resident felt dis-respected and staff’s interaction with R1 was unprofessional. The investigation also revealed S1 had several other inappropriate interactions with staff, residents and 3rd party agencies. S1 resigned from employment with the facility on 02/04/2021 during the completion of the investigation. The facility terminated employment with two other staff members on 12/04/2020 and 04/21/2021 for general disrespect of residents in care. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff member made inappropriate comments to residents. LPA’s conducted interviews with staff, residents, and reviewed documentation that revealed a few staff had made inappropriate comments to residents in care. The facility S1 resigned on 02/04/2021 during an investigation regarding inappropriate language and general disrespect of residents. The facility terminated S2 on 12/04/2020 and S3 on 04/12/2021 due to general disrespect of residents. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, Deficiency cited, Civil Penalty assessed, copy of report and appeal right emailed to Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210115105930
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
87468.1(a)(1)
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(a)...following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Administrator agreed to hold personal rights training with staff and about inappropriate language or interactions with residents and provide staff with samples of being inappropriate on the job and
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Based on interviews and documentation the licensee did not comply with the regulation above, residents were not being accorded dignity from a few staff at the facility which poses a potential Personal rights risk to residents in care.
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Mandated reporting requirements. Send staff training documentation along with staff signatures to CCL by 3/18/2022.
Civil Penalty assesed for repeat violation
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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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
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