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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850010
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:29:30 PM


Document Has Been Signed on 02/15/2024 05:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:CHERYL MARSHFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:130CENSUS: 74DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Adam Bramwell - AdministratorTIME COMPLETED:
04:00 PM
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At 9:57am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Interim Administrator, Adam Bramwell announced who he is and the reason for the visit.

Administrator and LPA conducted a full facility walk through and tour. LPA noted that the facility has a 130 person capacity and has a current census of 74. The facility exterior has walking path around the entirety of the facility and a covered main entrance. There is a designated smoking area just out side the dining-room entrance that has a covered gazebo on the side of the facility. LPA noted that the memory care unit of 15 resident room with on suite bathrooms located in the back of the facility and has a fenced outdoor area that is also in the back of the facility, which has tables and umbrellas for shade. LPA noted that the facility has a outdoor courtyard in the middle of the facility which also has tables and umbrellas for shade. LPA did not observe any issues or violations on the outside areas of the facility. LAP noted that this facility is two stories, it has 4 wings. On the first floor there area 35 resident rooms with on suite bathrooms, On the second floor there are 50 resident rooms with on suite bathrooms. LPA entered a sample of rooms (10) rooms and noted that all rooms had working lights, ample storage, working appliances and non-skid mats in the showers. LPA observed that there is a medication room, physical therapy room, laundry room, snack bar area with seating, beauty shop, and an tv activity room on the second floor. LPA noted that all three stair wells had emergency fire chair at the top of the stairwells. LPA noted that the dining room, kitchen, laundry room, staff room, maintenance room and employee entrance on the first floor on the north side of the building. LPA noted that the front entrance has offices and reception desk, and a lounging room for residents. LPA note that there are assorted offices on both the first floor and second floor. LPA noted that there were fire extinguishers placed all throughout the facility, all prime and charged in the green. LPA observed working carbon monoxide detectors through out the facilty. LPA noted that all walkways and entrances were free and clear of debit. Administrator and LPA conducted a full tool module review and no violations of or citations were noted. One Technical Violation was issued on late Administrator Certificate which will be corrected on May 22, 2024.
Exit interview, report read, no violations, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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