405850010-7-7-2026-29-AS-GHTO-DVRRP3-20260707131117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850010
Report Date: 07/07/2026
Date Signed: 07/07/2026 01:13:58 PM

Document Has Been Signed on 07/07/2026 01:13 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR/ DIRECTOR:	ADAM BRAMWELL		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 130		CENSUS: 100	DATE:	07/07/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Administrator - Adam Bramwell		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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At 9:20am, on 7/7/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management – Incident visit. LPA met with Administrator Adam Bramwell, announced who he was and the reason for the visit.

On 2/27/2026 at 11:43 p.m., the Administrator emailed the LPA to report that, during an audit conducted earlier that day by Omnicare pharmacy staff, multiple bottles of liquid narcotic medications were found to be missing. The Administrator stated that a full investigation was underway with the involvement of local law enforcement.

On 3/2/2026 at 10:20 a.m., the LPA spoke by phone with the Administrator and the previous Health and Wellness Director about their internal investigation. They reported that eight (8) bottles of liquid narcotic medication were missing from the locked medication refrigerator in the medication room located on the first-floor. These medication bottles are kept inside their original packaging box with the pharmacy label. According to their investigation, a hospice nurse managed medications for two of the residents with missing medications and confirmed they observed the two medication bottles they managed were present on 2/26/2026 at around 11:00 a.m. Later that same day, at about 7:00 p.m., Staff #2 (S2) checked all eight medications for refill needs and confirmed that all eight bottles were present in their labeled boxes. On 2/27/2026 at about 11:00 a.m., Omnicare pharmacy staff discovered that the eight bottles were missing during a scheduled audit. The boxes with pharmacy labels were still in the refrigerator, but the medication bottles were not inside. At approximately 4:00 p.m. that day, the Administrator contacted local law enforcement.

(Continued on LIC9099-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 405850010
	VISIT DATE: 07/07/2026

NARRATIVE

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During a visit conducted by the LPA on 3/3/2026, the LPA conducted interviews and collected documentation, including med management documents. LPA later obtained police reports.

LPA interviews and record review revealed that the facility has a policy requiring narcotic counts at each medication technician (med-tech) shift change, typically at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Three medication carts are used in the facility, and each cart is typically assigned to a different med-tech per shift. During narcotic counts, outgoing med-techs confirm the presence of each narcotic in their assigned medication cart with incoming med-techs and document this on the facility’s “Controlled Substances Shift Change Count-Check-Sheet.” This count includes the liquid narcotics stored in the medication room refrigerator. Liquid narcotic medications for all three carts are stored together in the same refrigerator, and med-techs are responsible for verifying the medications assigned to their cart.

Staff reported that during the narcotic counts conducted on 2/26/2026 and on 2/27/2026 at 6:00 a.m., they did not check to ensure all the bottles were physically in the boxes. Interviews also revealed that during the 6:00 a.m. narcotic counts on 2/26/2026 and 2/27/2026, Staff #1 (S1) was acting unusually, attempting to rush the counting process and stating they needed to be somewhere.

A routine medication audit had been scheduled for the morning of 2/27/2026 to be conducted by Omnicare pharmacy, which supplies most resident medications. During the audit, at approximately 11:00 a.m., Omnicare staff discovered the eight (8) bottles of liquid narcotics were missing.

The eight (8) missing medications are two (2) bottles of liquid lorazepam 2mg/mL (one bottle had approximately 24mL left and the other unused at 30mL) and two (2) bottles of liquid oxycodone 30mg/mL (one bottle had approximately 24.75mL remaining and the other unused at 30mL) belonging to Resident #1 (R1); two (2) full bottles (30mL) of liquid lorazepam (2mg/mL) belonging to Resident #2 (R2); one (1) open bottle with approximately 28.75mL remaining of liquid lorazepam (2mg/mL) belonging to Resident #3 (R3); and one (1) open bottle with approximately 27.5mL remaining of liquid lorazepam (2mg/mL) belonging to Resident #4 (R4).

(Continued on LIC9099-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 405850010
	VISIT DATE: 07/07/2026

NARRATIVE

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At approximately 11:30 a.m., the previous Health and Wellness Director notified the Administrator, who instructed staff to verify that the bottles were in fact missing. Interviews revealed that by the 2:00 p.m. shift change the medications had been confirmed missing, law enforcement had not yet been contacted, and med-tech staff did not want to conduct another narcotic count until the missing medications were reported to law enforcement. Interviews revealed that the Administrator did not get directly involved until this point. Administrator states that when they were notified of the missing medications they were caring for a short staffed kitchen since it was lunch time and wanted to ensure an internal investigation was conducted to make sure the medications were indeed missing before notifying local law enforcement. They were in communication with the corporate office notifying them of the missing meds and had additional administrative tasks to handle, a management position interview and resident care meeting. Records show that at approximately 4:00 p.m., the Administrator contacted local law enforcement.

Staff stated that on the night of 2/27/2026 to 2/28/2026 there were three staff there that night a care staff in assisted living, a care staff in memory care and a med-tech. Witnesses stated that at approximately 1:00 a.m. on 2/28/2026, S1 arrived at the facility, they were not acting themselves, and asked the other staff for the medication cart keys. Staff did not provide S1 the keys and asked S1 to go home, but they stayed. S1 was also reportedly focused on a small brown bottle in the med-tech room labeled nitroglycerin. Staff removed the bottle from S1, and it was later discovered to contain eleven (11) clonazepam 2mg tablets. Staff stated that S1 did not attempt to harm anyone or perform resident care; however, during the shift, S1 began slurring their speech, became unsteady, and eventually fell asleep in a chair outside the med-tech room. At approximately 7:00 a.m., staff notified the Health and Wellness Director that S1 was asleep in the chair and could not be awakened. At approximately 7:45 a.m., the Health and Wellness Director contacted local law enforcement. When law enforcement arrived, S1 had awakened and was in the memory care unit of the facility. Law enforcement escorted S1 out of the facility and it was later determined that S1 was in possession of the missing medications.

Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2026 01:13 PM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 07/07/2026 at 08:27 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/07/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/08/2026 Section Cited CCR 87468.2(a)(25)	1 2 3 4 5 6 7	Personal Rights (a) Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator states S1 has not returned to the facility since 2/28/2026 and their continued employment is dependent on the outcome of this and law enforcement investigations. The locks on the med-room and refrigerator have been changed. The facility changed their policy to only store...
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited when S1 stole multiple resident’s medications including narcotic medications, which posed an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	liquid narcotic medications that a resident is actively taking. The Administrator states they will review the theft and loss program at the the next all staff meeting on 7/8/2026 and email the LPA the meeting minutes and staff roster on or before 7/10/2026.
	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.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC809 (FAS) - (06/04)

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