405850010-8-29-2024-29-AS-KBUY-D8MLRH-20240830085909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 08/29/2024
Date Signed: 08/29/2024 09:55:31 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
11/01/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20231101084515

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: 90	DATE:	08/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Adam Bramwell		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sexually abused while in care.
Resident sustained unexplained bruising while in care.
Staff do not ensure that resident takes medication as prescribed.
Staff do not ensure resident's incontinence needs are meet.
Staff do not assist residents with showering.
Staff do not provide resident with housekeeping service.
Staff do not ensure that resident's dietary needs are met.
Staff engaging in food preparation are not observing sanitation practices.
Staff do not ensure that the facility is maintained sanitary.

INVESTIGATION FINDINGS:

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At 9:30am on 08/29/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to deliver the final findings to all the allegation to this complaint. LPA met with facility Administrator Adam Bramwell, announed who he is and the reason for the visit.

As to the allegation of, “Resident sexually abused while in care.” It was alleged that Reporting Party (RP) was told by Staff that Resident 1 (R1), had stated “He raped me”. It was discovered through interviews, observation and documentation that on 11/02/2023, LPA Jeffries attempted to conduct an interview with Resident 1 (R1). R1 was cognitively unable to answer questions of LPA when asking basic screening questions (ie: what is your name? Do you know where you are right now?), R1 did not answer. LPA noted that approximately 15 minutes after the attempted interview, R1 was yelling several profanities at staff. On 11/02/2023, LPA interviewed Wellness Director (S1). S1 stated that the facility has been aware of R1’s statements of alleged sexual abuse and facility investigated pertaining to R1’s statements;
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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 4

Control Number 29-AS-20231101084515

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: 08/29/2024

NARRATIVE

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S1 stated that R1 denied any sexual acts that have happened while in the facility, additionally, there are no male staff currently or recently assigned to the memory care unit where R1 resides. S1 stated that staff that work with R1 were instructed to monitor who enters or exits R1’s room, staff have not observed any male enter R1’s room. S1 stated that R1 exhibits overt sexual language when R1 is upset which has been a consist behavior from the beginning of R1’s residing at this facility, according to S1 interview on 11/02/2024. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset.. On 11/02/2024, LPA, S1 and facility Administrator conducted an interview with S2. S2 stated that they had a conversation with a staff member about R1 but did not provide any other details about R1 other then what R1 stated, “He raped me”. Based on interviews, observations and documentation, at this time there is not enough evidence to support the allegation of, “Resident sexually abused while in care.” and is unsubstantiated at this time.
As to the allegation of, “Resident sustained unexplained bruising while in care.” It was alleged that Resident had bruises all over their body and look like finger bruises. It was discovered through interviews, observations, and documentation that, on 11/02/2024, LPA Jeffries attempted to interview R1, and R1 was not responsive to basic screening questions. LPA did observe one red bruise on the left forearm of R1 that was approximately 2” with round shape and no indication in the shape that could determine how the bruise may have occurred. On 11/02/2023 LPA Jeffries reviewed R1’s LIC602 (Physicians Report) that indicated a primary diagnosis of Edema. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset. S3-10 stated they have not observed any other bruising on R1’s body other than the left forearm bruise. Based on interviews, observations, and documentation there is not enough evidence to support the allegation of, “Resident sustained unexplained bruising while in care.” and is unsubstantiated at this time.
As to the allegation of, “Staff do not ensure that residents take medication as prescribed.” and, “Staff do not ensure residents’ incontinence needs are met.” It was alleged that staff do not properly administer medication to R2 and R2 “stashed” medication in their drawer as well as R2 left in soiled briefs for extended periods. On 11/02/2023 LPA Jeffries conducted an interview with R2, R2 stated that they have always take medication when provided by staff. R2 denied hiding or stashing medications at any time. R2 stated that staff do a good job with incontinence needs and medications including prescribed ointments as need. LPA observation during interview, noted that no medications or ointments were in R2’s drawers. On 11/02/2024 LPA Jeffries reviewed R2’s LIC602 (Physicians Report) which indicated UTI as a secondary diagnosis.
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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231101084515

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: 08/29/2024

NARRATIVE

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LPA also observed Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR)for R2 and did not find any missed medications. LPA reviewed Physician notes on facility visit of R2 on 08/22/2023 and 09/05/2023 both listing frequent UTI’s. On 11/03/2023, LPA reviewed facility serious incident reports (SIR) and did not find any SIR’s with R2 as the subject. LPA interviewed S3-10, who all stated that medications are always given as prescribed to their knowledge. S3-S10 all stated that all residents are always monitored for incontinence and cared for when incontinence care is needed. Based on interviews, observation, and documentation, there is not enough evidence to support the allegation of, “Staff do not ensure that residents take medication as prescribed.” and “Staff do not ensure residents’ incontinence needs are met.” are both unsubstantiated at this time.
As to the allegation of, “Staff do not assist residents with showering.” It was alleged that R2 and R3 were not regularly showered. It was discovered through documentation and interviews that on 11/02/2023 LPA Jeffries reviewed Admissions agreements, Level of Care Plans, Shower Schedules/Refusal documents for R2 and R3. Both R2 and R3 were assessed at the highest level of care (facility Level 6) provided by the facility. On 11/02/2023, LPA interviewed R2, who stated that the staff take care of bathing needs daily, most often while in bed. R2 stated that staff did a good job of keeping R2 clean. On 11/02/2023, LPA Jeffries conducted and interview with R3 who stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. LPA noted that R3’s facility care plan outlines daily shower as confirmed by R3. On 11/02/2023, LPA Jeffries conducted interviews of S3-S10 who all stated, stated that all residents are monitored at all times for incontinence and cared for when incontinence care is needed. Based on interviews, documentation, and observations, at this time there is not enough evidence to support the allegation of, “Staff do not assist residents with showering”. and is unsubstantiated at this time.
As to the allegation of, “Staff do not ensure that residents’ dietary needs are met.”
It was alleged that staff “throw” food in front of R2, then leave. It was discovered through documentation and interviews that on 11/02/2023, LPA Jeffries interviewed R2. R2 stated that they have never had any issues with food service at this facility. R2 denied that staff threw or left food for R2 at any time. On 11/02/2023, LPA conducted interviews with S3-S10, all staff were aware that R2 required meals to be set up for R2. All denied throwing or leaving food for R2 that R2 was not able to consume. On 11/02/2023 LPA reviewed R2’s LIC602 (Physicians Report) which indicated that R2 is able to feed self, with “set up assistance.” At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ dietary needs are met.” 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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20231101084515

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: 08/29/2024

NARRATIVE

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As to the allegations of, “Staff do not provide residents with a housekeeping service.”, “Staff do not ensure that the facility is maintained sanitary.”; and “Staff engaging in food preparation are not observing sanitation practices.” It was alleged that; Kitchen staff do not wash hands when preparing meals for residents. And dining mats are not sanitary. And R3’s room smells of urine and is not cleaned. It was discovered through interviews, photographs, documentation, and observations that, on 11/02/2024 LPA Jeffries conducted an interview with R3. R3 stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. On 11/02/2023, LPA Jeffries interviewed S3-S10 who all confirmed R3 had incontinence behaviors that are continuously being addressed by staff and housekeeping staff. S3-S10 all confirmed that housekeeping staff will address any cleaning problems as needed on top of their normally schedule cleaning tasks. On 11/02/2023 LPA reviewed facility housekeeping schedule and noted no gaps or call offs in house keeping schedule. On 11/02/2023 LPA Jeffries observed kitchen staff preparing lunch, all were wearing black gloves. LPA interviewed Kitchen Staff S13 who stated that all food preparation is conducted with gloves for hygiene and sanitary reasons. LPA observed and photographed dining place mats and noted all were clean and free of stain and foods. On 04/09/2024, at approximately 10:50am, Administrator Adam Bramwell and LPA Jeffries conducted a visual inspection of all 14 bathrooms in the memory care unit. LPA photographed and noted that 13 of 14 bathrooms were clean and in good working order. LPA noted that the one bathroom in question was cleaned, however the floor was sticky. This was discovered to not be a sanitation issue but a floor material issue that is being addressed by the administrator. On 04/09/2024, LPA Jeffries interviewed Memory Care Staff 5, 11, and 12 (S5, S11, and S12), who all stated that their job duties included cleaning restrooms as needed. S5, S11 and S12 all stated that they knew they could call housekeeping on the radio if there was a need to have a residents restroom cleaned due to an immediate need. LPA noted that there was no evidence on this visit to indicated that staff do not ensure resident’s restrooms are cleaned and sanitized. LPA reviewed documentation (Job Description) of staff duties of Pegasus Senior Living for the position of Care Partner that included but not limited to, “Maintains clean, neat, comfortable, safe environment for Residents, Staff and visitors, including housekeeping services for Residents.” Which S5, S11, and S12 all acknowledged in interviews on 04/09/2024. At this time, there is not enough evidence to substantiate the allegations of, “Staff do not provide residents with a housekeeping service.” “Staff engaging in food preparation are not observing sanitation practices.” and “Staff do not ensure that the facility is maintained sanitary.” and all are unsubstantiated at this time.
Exit interview, report read, 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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

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