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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 03/25/2023
Date Signed: 03/25/2023 10:47:42 AM

Unsubstantiated


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
01/12/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220112095629
FACILITY NAME:CRESTON VILLAGE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:CHERYL MARSHFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:130CENSUS: 77DATE:
03/25/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maintenance Director/ Brain LloydTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Facility requires staff to work during illnesses.
Night staff are sleeping during shifts.
Night staff leave facility prior to day shift coming to relieve them.
Staff are not ensuring residents' incontinence needs are being met.
Residents do not have a room that accommodates wheelchair access.
Residents' beds have soiled linens.
Residents' room does not have heat.
Staff do not have training to appropriately care for residents.
Facility is not clean, safe, sanitary nor in good repair.
INVESTIGATION FINDINGS:
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 At 10:00am on 03/25/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to deliver final findings to the allegations above to this complaint. LPA met with Maintenance Director/ Brain Lloyd announced who he was and the reason for the visit.
As to the allegation of, “Facility requires staff to work during illness.” It was discovered through interviews and documentation that facility staff were required, upon initial entry to the facility for each shift, to screen for symptom of illness, known recent contacts of ill persons, alternate work environments, and temperature, and sign and notate any of the possible symptoms of illness. LPA reviewed each staff self-screening, with staff signatures for the months of October 2021 through January 2022 and there were no staff that entered the facility with symptoms or relative conditions related to possible symptoms as indicated from the self-screening sign-in documentation. Interviews of Staff S2 through S6 did not reveal any requirement, tactic, or coercion that required staff to work during an illness. LPA reviewed facilities attendance policy and did not find any regulation violations within the policy.
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: 03/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023
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 5
Control Number 29-AS-20220112095629
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: 03/25/2023
NARRATIVE
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 LPA reviewed seven staff write ups about excessive call offs during the months of October 2021 through January 2022. All write ups were adhered to attendance policy. LPA interviewed Administrator Cheryl Marsh on October 27, 2022, which did not reveal any requirement, tactic, or coercion for staff to attend work while sick, and outlined the use of two staffing agencies, Maxim and Brightstar, to utilized fill in for staffing needs. Based on interviews, and documentation there is not enough evidence at this time to support the allegation of, “Facility requires staff to work during illness.”, and is therefore, unsubstantiated at this time.

As to the allegation of, “Night staff are sleeping during shifts.” LPA interviewed Administrator Cheryl Marsh who stated the facility had a complaint from a staff that another staff was sleeping during their NOC shift in memory care. Administrator directed Staff 1 (S1) to conduct unannounced visits to the facility overnight to check on staff performance and address the complaint. S1 conducted at least 4 unannounced visits and did not find any staff violating company policy or sleeping. LPA interviewed staff and there was no indication of staff sleeping on their shift during this time frame (November 2021-January 2022) . Based on interviews, and documentation there is not enough evidence at this time to support the allegation of, “Night staff are sleeping during shifts”, and is therefore, unsubstantiated at this time.

As to the allegation of, “Night staff leave facility prior to day shift coming to relieve them.” Due to a complaint of staff sleeping on shift, Administrator directed Staff 1 (S1) to conduct unannounced visits to the facility overnight to check on staff performance and address the complaint. S1 conducted at least 4 unannounced visits and did not find any staff violating company policy or leaving early. LPA interviewed staff and there was no indication of staff leaving early on their shift during this time frame. LPA reviewed staff timecards from January 2022 and observed that shift starting times in the morning shift were staggered for coverage. LPA did not find any days where there were unusual gaps in shift changes in the overnight to AM shifts during the months of October 2021 through January 2022. Interviews of S1 through S6 did not reveal any knowledge or evidence of staff leaving before end of shift. Based on interviews, and documentation there is not enough evidence at this time to support the allegation of, “Night staff are sleeping during shifts”, and is therefore, unsubstantiated at this time.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220112095629
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: 03/25/2023
NARRATIVE
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 As to the allegation of, “Staff are not ensuring residents' incontinence needs are being met.” It was discovered through interviews and documentation that October 2021 through January 2022 there were 14 residents that resided in the Memory Care Unit. 4 of 14 residents were identified through interviews of S2 and S4 to have chronic incontinence issues. Interviews of S2 through S6 did not reveal any unmet needs with incontinence during the time period of October 2021 through January 2022. Interviews of S1 through S6 discovered that shift specified duties were followed and no staff were aware of unmet needs pertaining to incontinence. LPA reviewed staff actual work schedules from October 2021 through January 2022 and found no staffing vacancies in the memory care unit during this time. LPA interviewed a witness (W1) who visited the facility during this time frame, through interview W1 indicated they were not aware of incontinence care issues. Based on Interviews, and documentation there is not enough evidence at this time to support the allegation of, “Staff are not ensuring residents' incontinence needs are being met.”, therefore the allegation is unsubstantiated at this time.

As to the allegation of, “Residents do not have a room that accommodates wheelchair access.” It was discovered through documentation, interviews, photographs, and multiple observations that the residents in room 237 did not have issues with accessing the bathroom amenities, doorways, or walkways of their room with their wheelchair. LPA Interviewed resident (R1) who resided in room 237 during the time of this complaint, interview revealed that both residents choose this specific room upon admission to the facility and the ambulatory status of both R1 and R2 was the same at the time of admissions as it was at the time of this complaint. In an interview with R1 who was the resident in room 237 during the time of this complaint, R1 stated that R1 and R2 made a request to change the sink to a different height to better accommodate R2’s wheelchair height, R1 stated that the facility replaced the sink in the bathroom of room 237 to accommodate the resident’s wheelchair height per request. R1 stated that the first sink was accessible, as well as functional, and the request was made for better convenience. LPA’s observations and photographs indicated that room 237’s door width and bathroom door width allow for access of wheelchairs. Interview with Administrator indicated that R1 and R2 had choice of room upon admission and facility made accommodations for this room as requested. Based on Interviews, and documentation there is not enough evidence at this time to support the allegation of, “Residents do not have a room that accommodates wheelchair access”, therefore the allegation is unsubstantiated at this time.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220112095629
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: 03/25/2023
NARRATIVE
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 As to the allegation of, “Residents' beds have soiled linens. “It was discovered through interviews and documentation that October 2021 through January 2022 there were 14 residents that resided in the Memory Care Unit. 4 of 14 residents were identified through interviews of S2 and S4 to have chronic incontinence issues. Interviews of S1 through S6 did not reveal any unmet needs with incontinence during the time period of October 2021 through January 2022. Interviews of S1 through S6 discovered that shift specified duties were followed and no staff were aware of unmet needs pertaining to incontinence. LPA reviewed staff actual work schedules from October 2021 through January 2022 and found no staffing vacancies in the memory care unit during this time. LPA interviewed a witness (W1) who visited the facility during this time frame, through interview W1 indicated they were not aware of incontinence care issues. Based on Interviews, and documentation there is not enough evidence at this time to support the allegation of, “Residents' beds have soiled linens” therefore the allegation is unsubstantiated at this time.
As to the allegation of, “Resident’s room does not have heat.” It was discovered through documentation and interviews that the heater in Room 237 broke and had to be fixed. LPA reviewed a repair invoice indicating the heater was functional, however it was noisy on 12/10/21, addressing the noise, parts for heater were ordered on or before 12/17/21 as indicated by purchase invoice from Direct Supply Equipment Furnishings (30222352) and arrived to the facility on 12/31/21. The heater was repaired on 01/03/22. LPA interviewed Administrator, who indicated they assured that room 237 had a working heater and ordered parts to address the noise the heater created. LPA interviewed residents about the heater and did not indicate that there was no heating in room 237 during the months of November and December of 2021. Based on Interviews, and documentation there is not enough evidence at this time to support the allegation of, “Resident’s room does not have heat” therefore the allegation is unsubstantiated at this time.
As to the allegation of, “Staff do not have training to appropriately care for residents.” It was alleged that memory care staff did not have adequate training per regulations. It was discovered through documentation and interviews that, facility employees working in the memory care unit had the initial 6 hours of dementia specific training in their initial training records. Four of the Six facility employees working in the memory care unit who were employed at least 12 months had the additional 2 hours and/or 8 hours annually of dementia specific training required by regulations to care for residents with dementia. The facility did utilize two staffing agencies, Maxim and Brightstar, to fill in for staffing needs that were supervised by appropriately dementia trained facility employees during their shifts. At this time there is not enough evidence to support the allegation of, “Staff do not have training to appropriately care for residents.” therefore is unsubstantiated at this time. CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220112095629
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: 03/25/2023
NARRATIVE
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 As to the allegation of, “Facility is not clean, safe, sanitary, nor in good repair.” It was alleged that the residents’ rooms were not clean. It was discovered through documentation and interviews that, during a COVID-19 outbreak in September of 2021 and January in 2022, the facility had fewer staff available due to the COVID-19 outbreak. As a result, available staff pitched in to cover housekeeping duties. Administrator told LPA that, herself and the health director helped empty trash cans and clean frequently touched surfaces due to the outbreak to mitigate the COVID-19 positive staff call offs. Administrator stated that all of the facility staff that could work, performed extra duties to maintain the facilities conditions during the COVID-19 outbreaks. LPA has conducted 4 facility visits from October 2022 to March 2023 and has made no observations indicating that the facility is not clean, safe, sanitary, nor in good repair.” Additionally, repairs are documented and conducted in a timely manner based on facility work history report for the months of October 2021 through January 2022 were done in a timely manner. Based on Interviews, and documentation there is not enough evidence at this time to support the allegation of, “Facility is not clean, safe, sanitary, nor in good repair” therefore the allegation 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: 03/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5