405850010-5-25-2023-29-AS-KBUY-CSC49R-20230530185446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 05/24/2023
Date Signed: 05/25/2023 11:56:44 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
10/25/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20221025100703

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: 68	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cheryl Marsh / Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident physically assaulted another resident in care.
Resident is not given showers.
Facility did not provide resident with soap.
Facility not properly caring for resident's wounds.
Resident's responsible party did not receive a copy of the facility contract.

INVESTIGATION FINDINGS:

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At 10:00am on 05/25/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA, met with Administrator Cheryl Marsh, announced who he was and the reason for the visit.

As to the allegation of, “Resident physically assaulted another resident in care.” It was discovered by documentation, and interviews that on 10/22/2022, R1 was sitting with peer at a dining table at approximately 1:00pm, when staff turned their back to table, R1 was sitting with R2, R2 struck R1 in the area of R1’s chest. S2 and S3 separated the residents, assessed for injuries, none were noted on R1 or R2. Out of precaution facility contacted 911. EMT arrived and accessed R1 and found no need for transport due to no injury. Facility contacted R1’s Physician, Responsible Party, Community Care Licensing, Ombudsman and submitted Unusual Incident Report (LIC 624 (4/99) on 10/28/2022.

CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 29-AS-20221025100703

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: 05/24/2023

NARRATIVE

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In interviews of R1 by EMT on 10/22/2022 and by LPA on 10/27/2022, R1 indicated no recollection of assault event. Facility had more then enough staff on shift during this time. Facility exercised due diligence, notifications and immediate action pertaining to the circumstances of this incident. There is no evidence to support that the facility was understaffed or negligent in, “Resident physically assaulting another resident in care,” and the allegation is unsubstantiated at this time.

As to the allegation of, “Resident is not given showers.” It was discovered through interviews, and documentation that R1 had showers scheduled by staff 7 days per week. From June 2022 through October 2022 there are 21 documented refusals for showers by R1. Interviews with Staff 1 – 5 all confirm that R1 would often refuse showers. Staff 1 – 5 stated they document and report when residents refuse showers. LPA attempted to interview Residents 1 – 6 In memory care as to shower frequency and schedule, however all answers were inconclusive. At this time there is not enough evidence to support the allegation of, “Resident is not given showers.” And is unsubstantiated at this time.

As to the allegation of, “Facility did not provide resident with soap.” It was discovered through documentation, interviews and observation that it was observed by LPA that there was pearl-white soap in the soap dispenser on the bathroom sink in R1’s room that was free and clear of grime and/or other substance on 10/27/2022 and 11/17/2022 LPA did not observe any grim or forging substances on the soap dispenser on the wall of the bathroom. Staff duty logs indicate that staff address restocking bathrooms on a weekly basis and as needed. Interviews with S1, S2, S3, S4, S5 and S6 all indicated that soap and other bathroom amenities are stocked regularly and as needed. Based on interviews, documentation, and observations, there is not enough evidence at this time to support the allegation of, “Facility did not provide resident with soap.” and is unsubstantiated at this time.

As to the allegation of, “Facility not properly caring for resident’s wounds.” It was discovered that R1 was in need of Podiatrist evaluation as early as November 2022. The facility has a Podiatrist that makes routine bi-monthly rounds, R1 was seen by this Podiatrist on 10/29/2022, 12/13/2022 and refused treatment, again on 12/27/2022 where toenails of R1 were clipped. Additionally, facility contacted R1’s primary physician in January 2023 to evaluate and address R1’s feet and skin care needs. Primary Physician and Nurse Practitioner addressed and treated both foot and skin conditions on January 11, 2023, according to documentation. Based on documentation there is not enough evidence to support the allegation of, “Facility not properly caring for resident’s wounds.” and is unsubstantiated at this time.
CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221025100703

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: 05/24/2023

NARRATIVE

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As to the allegation of, “Resident’s responsible party did not receive a copy of the facility contract.” It was discovered that R1’s initial admission agreement (contract) was signed on September 30, 2017. When R1 added two children as Power of Attorney (POA) in October of 2021, both POA’s were provided copies of the original contract from September 30, 2017. In November of 2021, R1 moved to a higher level of care and into the facilities memory care unit. This was a change of level of care and not a change in the contract. At the time this complaint was issued, POA was assuming that a new contract was necessary for the change in higher level of care and moving to the memory care unit. During the LPAs investigation, the POA had received a copy of the original contract in 2017, in addition to receiving a copy of the original contract in October of 2021. Based on interviews with POA and Administrator, the original contract was provided to the responsible party when requested and the allegation of, “Resident’s responsible party did not receive a copy of the facility contract.” Is unsubstantiated at this time.

Exit interview, report read, report singed, and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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