405850010-5-28-2021-29-AS-KBUY-C7HURR-20211005154909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:29:24 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
05/27/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210527092347

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: 82	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Erika Lopez/Bisniss Office Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to meet resident’s needs.

Medication is accessible to resident.

Facility accepted resident without complete physician’s report.

Facility does not promptly respond to resident's representative.

INVESTIGATION FINDINGS:

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At 8:30am on 05/28/2021, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct and 10 day complaint investigation on the allegations listed above. LPA met with Buisness Office Manager (BOM) Erika Lopez and explained the reason for the visit.
BOM and LPA walked the facility to resident R1's room. At 8:50am, BOM and LPA were granted access to resident room by R1. LPA and BOM explained to R1, they were testing the call button and checking for safety issues, At 8:53am BOM pressed the call button, BOM and LPA waitied 12 minutes with no response to the call button. BOM and LPA then walked to the Nurses Station to ensure the call button was functioning properly. BOM and LPA observed that the call button for R1 was working properly and had not been cleared at that time for the call button for R1. At 9:09am the call button had been pressed 14 minutes and 15 seconds and still not cleared. LPA then reviewed resident records.
LPA notes that there are 6 allegations to this complaint. The following three allegations were able to be determined at the time of this visit: 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) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20210527092347

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: 05/28/2021

NARRATIVE

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As to the allegation of, "Facility failed to meet resident’s needs." It was discover through interviews, documentation and observation that R1 has had no needs unmet at this facility. R1 stated that they liked the facility and have had no problems what so ever at any time. R1's Physician's Report (LIC602) states that R1 is capable of all self-care and has the right to refuse baths and clothes change assistance. LPA observed R1 to have a smile and good attitude during interview visit and did not observe any conditions on R1's person to indicate needs are not being met. Therefore, the allegation of, " Facility failed to meet resident’s needs." is unsubstantiated at this time.

As to the allegation of, "Medication is accessible to resident." It was discovered through interview on 05/28/20201 and review of R1 documentation that R1 is capable of administration of own medication. R1's Physicians Report (LIC602A) dated 04/20/2021 indicated that R1 is capable to self administration of own medication. Medication for R1 is kept in R1's locked single occupancy room. Therefore the allegation of "Medication is accessible to resident". is unsubstantiated at this time.

As to the allegation of "Facility accepted resident without complete physician’s report." It was discovered by documentation review on 05/28/2021 that R1 has a complete Physician Report (LIC602A) dated 04/202/2021 on file with the facility. Therefore the allegation of "Facility accepted resident without complete physician's report." is unsubstantiated at this time.

As to the allegation of, 'Facility does not promptly respond to resident's representative."It was discovered through interview on 05/28/2021 and documentation review that R1 is listed as a joint Power of Attorney (POA) for medical and financial decisions. It is also documented on R1's Physician's Report (LIC602A) that R1 is capable of making decisions on self-care, such as bathing, dress and grooming self. F1 and R1 stated that R1 had refused bathing on multiple occasions. Because R1 is joint party to the POA on file and LIC602A indicated that R1 is capable of making own decisions of slef-care, there were no additional instruction in the admissions agreement to promptly notify residents representative, on the refusal to bathe or change of clothes (dress/groom), therefore the allegation of, "Facility does not promptly respond to resident's representative." 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: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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