405850010-12-19-2024-29-AS-KBUY-DCCSYY-20241227131820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:13:29 PM

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
05/06/2024 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20240506140046

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR:	ADAM BRAMWELL		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	130	CENSUS: 96	DATE:	12/19/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator, Adam Bramwell		TIME COMPLETED:	12:16 PM

ALLEGATION(S):

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Facility failed to notify responsible party/physician in residents change of condition.

Facility did not provided change of contract notification.

Facility did not observed residents change of condition.

Facility did not follow terms of admission agreement.

Facility staff are not properly trained.

INVESTIGATION FINDINGS:

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At 8:45am on 12/19/2024, Licensing Program Anaylist (LPA) Jeffries arrived to the facility unannounced to issue final finding to the allegations to this complaint. LPA met with Administrator Adam Bramwell, annoucned who he is and the reason for the visit.

As to the allegations of, “Facility failed to notify responsible party/physician in residents change of condition.”, “Facility did not observed residents change of condition.”, “Facility did not follow terms of admission agreement.”, and “Facility did not provided change of contract notification.” It was alleged that there was a lack of communication, and not replying to calls or emails to the family or physician’s a notification in R1’s change of condition. It was discovered through documentation and interviews of the following: On 05/15/2024, LPA Jeffries reviewed R1’s Admissions Agreement dated 02/15/2024, this Admissions Agreement was initialed and singed in all applicable notations with the following notable acknowledgements:
CONTUNED 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: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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-20240506140046

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: 12/19/2024

NARRATIVE

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R1 identified and initialed that this agreement was with the facility corporation, R1 and “self” indicating that R1 was independent of a designated representative by the contract. It is noted that there was a clause in the contract that in the event of Death, F1 was designated as the person to remove R1’s property. There were no other items in the contract as to a representative or designated person of R1 in this Admission Agreement. Additionally, on 05/15/2024, LPA reviewed R1’s Physicians Report (LIC602) dated 02/13/2024, two days prior to R1’s move in date to the facility, which did not notate any cognitive decline, and noted that R1 could leave the facility unassisted. On 05/15/2024, LPA reviewed, R1’s Central Coast Home Health Care, Admission Service Agreement, singed and dated on 02/18/2024 which indicated and marked as “I DO NOT have a durable Power of Attorney for Health Care.” Which was singed by R1 on 02/18/2024. On 05/06/2024 and 05/15/2024, LPA Jeffries reviewed 9 pages of transcripts submitted by F1 indicating outlining, weekly to daily communications with Administrator, Adam Bramwell, Facility Wellness Director (S1) pertaining to R1’s medical appointments, medication changes and concerns, billing explanations, insurance benefits, and general condition of R1. On 05/06/2024, LPA interviewed F1, who stated that they have been in communication with Administrator Adam Bramwell, and S1 through email, text, and phone calls multiple time a week during R1’s stay at the facility. On 05/10/2024 LPA Jeffries interviewed Administrator, Adam Bramwell who stated that they had continuous contact with F1 through phone (mostly in the evenings due to global location of F1), text, and emails. On 05/10/2024 LPA Jeffries interviewed S2 who stated that they have had continuous contact with F1 through emails during F1’s stay at the facility. LPA noted Based on documentation, and interviews, there in not enough evidence to support the allegations of, “Facility failed to notify responsible party/physician in residents change of condition.”, “Facility did not observed residents change of condition.”, “Facility did not follow terms of admission agreement.”, and “Facility did not provided change of contract notification.” and are all 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: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240506140046

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: 12/19/2024

NARRATIVE

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At to the allegation of, “Staff are not properly trained.” It was alleged that on February 17th Staff 3 (S3) and Staff 4 (S4) did not know how to change the portable oxygen bottle for R1. It was discovered through interviews and documentation that on 05/06/2024, LPA conducted a phone interview with W1. W1 stated that R1’s portable oxygen tank was delivered “either the 16th or the 17th of February. 12/18/2024 LPA Jeffries conducted phone interviews with S4 who stated that Facility Health Care Director provided in “impromptu” training to all care staff that were working 02/19/2024 a training on the specific functions of R1’s portable oxygen tank. S1 stated that they have over a year experience as Medication Technician and Care Giver and has had experience and prior training with Oxygen for residents. LPA noted that the arrival of the new equipment (R1’s portable oxygen tank) on a weekend did not allow reasonable time for staff training. LPA noted that the “impromptu training took place on 12/18/2024 at the first available date for training by a qualified trainer. LPA reviewed all staff training records that were working at the facility on 12/17/2024 which included S3, S4, S5, S6, S7, and S7. S3-S7 all had met or exceeded the annual number of hours of training per regulations. LPA noted that the facility exercised due diligence in the training of the new equipment (R1’s portable oxygen) on the first available date. At this time there is not enough evidence to support the allegation of, “Staff are not properly trained,” and is 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: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6

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
05/06/2024 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20240506140046

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR:	ADAM BRAMWELL		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	130	CENSUS: 96	DATE:	12/19/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator, Adam Bramwell		TIME COMPLETED:	12:16 PM

ALLEGATION(S):

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Facility failed to provide resident with correct medication dosage.

INVESTIGATION FINDINGS:

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At 8:45am on 12/19/2024, Licensing Program Anaylist (LPA) Jeffries arrived to the facility unannounced to issue final finding to the allegations to this complaint. LPA met with Administrator Adam Bramwell, annoucned who he is and the reason for the visit.

As to the allegation of, “Facility failed to provide resident with correct medication dosage.” It was alleged that, R1 was prescribed 40mg of Lasix once a day, “when (R1) should be on 40mg twice a day.” Per Witness 1 (W1). It was discovered through medical records and facility documentation that R1’s admission date to the facility was 02/15/2024 and physically entered the facility once released from the hospital on 02/16/2024. LPA reviewed Hospital discharge instructions for R1 dated 02/16/2024 with medication orders for Furosemide (Lasix) 40mg BID (twice per day) per Physician 1 (Phys1). Facilities Centrally Stored Medication Record (CSMR) dated 02/14/2024 shows Furosemide 40mg, twice per day started on date 02/17/2024 per Phys1.

Substantiated

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: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20240506140046

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: 12/19/2024

NARRATIVE

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On 02/19/2024 R1 had a follow up doctor’s appointment where new medication orders for R1 which changed the Furosemide 40mg to 1 tab PO qDay (Once per day) under the supervision of Phys2. On 03/05/2024, at the request of the W1, facility submitted a request to Phys3 for R1 to have Furosemide 40mg BID. On 03/07/2024 a return fax order which stated, “R1 can increase Furosemide 40mg BID for 5-7 days until swelling improves…” The final order that the facility received was for Furosemide 40mg BID was received on 03/28/2024 from Phys3.
Upon admission to the facility on 02/16/2024, R1’s Medication Administration Record (MAR) from the facility shows R1 to have Furosemide 40mg administered twice per day (8am and 12pm) on date February 16, 17, 18, and 19, as prescribed by Phys1, which are the correct dosage time per Physicians orders as referenced above. Orders dated 02/19/2024 by Phys2, prescribing Furosemide 40mg qDay (once per day) as noted above where not followed according to Physician orders. As evidence by the facilities MAR, which shows that R1 continued to received Furosemide 40mg BID, from the dates of February 19, 20, 21, 22, 23, 24, 25, 26, 27, 28. On February 29th facility MAR shows Furosemide 40mg administered at 8am and Discontinued (DC) for the 12:00 pm time, however the facility did not present any physicians orders for this DC notation on February 29th. The facility March of 2024 MAR notes that the correct time and dosage of Furosemide 40mg as per Physicians orders were followed from March 7-12 was followed a per Physician Orders, as evidence of the facility MAR and the faxed order from Phys3 on 03/07/2024. Facility March MAR also noted that no Furosemide 40mg was administered between the dates of March 15, 16, 17, 18, 19, 20, and 21 as per Physicians order. LPA Jeffries reviewed facility documents titled Incident Notification dated 04/17/2024, indicating that R1 was transported to the hospital for shortness of breath, however this was not reported and documents requested were not provided to determine how long R1 was in the hospital based on that facility incident report. Which puts the facility March 2024 MAR for the dates of March 15-21 in question as there is no note of Furosemide 40mg in question of multiple doctors’ orders which do not specify to DC or continue once per day. Facility MAR for March and April show that Furosemide 40mg was administered per Physicians order based on last prescription from Phys3 of Furosemide 40mg BID. Based on MAR, Physicians Orders, and CSMR, there is enough evidence to show that during the time period of February 19-28, R1 was not administered medication by the facility as prescribed by a physician. Therefore, the allegation of, ““Facility failed to provide resident with correct medication dosage.” Is substantiated at this time.

Exit interview, report read, citation issued, appeal rights 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: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20240506140046

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/20/2024 Section Cited CCR 87465(a)(5)(A)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical … provide for assistance in obtaining such care, by compliance with the following: (5) … Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed	1 2 3 4 5 6 7	Administrator agrees to conduct two hours of Medication training that includes medication initial intake, documentation, and medication distribution. Administrator will review and revise Medication Administration policy with all employees and proved LPA a copy of all
	8 9 10 11 12 13 14	for self-administration which have been authorized by the person's physician. This requirement was not met by evidence of MARs indicating medication not provided in accordance to Physicians order in February of 2024. Which poses an imminent risk to Residents in care.	8 9 10 11 12 13 14	staff 2 hour Medication training, as well as the facility’s current and updated medication distribution policy to LPA by 12/20/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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