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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 01/20/2022
Date Signed: 01/20/2022 05:17:56 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
01/20/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220120125841
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: 78DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff are not wearing face masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with Cheryl Marsh, Administrator, and explained the purpose of the visit.

LPA toured the facility and at 11:26 am observed Staff #1 (S1) not wearing a mask in the kitchen while preparing food. At 11:37 am, LPA observed Staff #2 (S2) wearing a mask below the nose in the Activity Room.
The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility S1 and S2 failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.

Exit interview conducted, deficiency cited, a copy of this report and appeal rights emailed to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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 2
Control Number 29-AS-20220120125841
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: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator has agreed to immediately implement mask wearing in the facility, hold Mask/Infectious Prevention training with all staff, and provide training records with all staff signatures to CCL by 1/27/22.
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Based on observations, the facility failed to ensure S1 and S2 were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2