405850010-2-24-2022-29-AS-JOLN-CBY2BC-20220224161455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850010
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:16:52 PM

Document Has Been Signed on 02/24/2022 04:16 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 75	DATE:	02/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Cheryl Marsh, Administrator		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst's (LPA's) Olson and De Leon conducted an on-site 1 year infection control annual visit to the facility above on 02/24/2022 at 9:50 AM. LPA's met with Administrator Cheryl Marsh and explained the purpose of the visit. LPA took a physical plant tour of the facility with staff. The facility has submitted a mitigation plan to the department, and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. All documentation is kept in a file. The entry station has hand sanitizer along with a thermometer. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The facility has a large courtyard for resident use with a couple umbrellas. All equipm ent and PPE supplies are kept in the storage closet. Medications are kept in a locked medication room. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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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Document Has Been Signed on 02/24/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above stairwell by door 7 did not have the required evacuation chair which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Administrator agreed to have a new chair ordered and installed. Send CCL a photograph on stairwell by door 7 by 2/25/2022.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by having memory care cabinets unlocked with cleaning supplies and a staff bathroom that was unlocked which had acrylic paint in the cabinets, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Administrator agreed to lock up all cabnets and train staff in regulation 87705 and send proof of locked items and training to CCL by 2/25/2022.

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above the courtyard had several unsafe items such as wood pallets, materials, holes, and uneven coverings which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/03/2022
	Plan of Correction
1 2 3 4	Administrator agrees to remove all unsafe items immediately and fix wholes and uneven services and send pictures to CCL by 3/3/2022. Administrator will immediately put up cones and caution tape.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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
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: 02/24/2022

NARRATIVE

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Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Health and Wellness Director is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has single rooms with restrooms and they are disinfected bi-weekly or daily in Memory Care. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke and carbon monoxide detectors thorough the facility.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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
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: 02/24/2022

NARRATIVE

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At around 10:35 AM LPAs noticed the Memory Care common area had an accordion door that was open. There is a sign that says “Staff Only” but the area was not locked and LPA Olson noticed cleaning products, lotion, staff food, coffee, and a Monster drink. These items were unlocked and easily accessible to any Memory Care resident. At 10:40 LPA Olson saw an unlocked door to a staff restroom. Staff on tour immediately closed door which then locked. LPA Olson asked to see the inside of the restroom. LPA Olson observed full bottles of Acrylic Paint in the unlocked cabinet. At 10:50 AM LPA Olson observed pallets, holes, and materials out in the Courtyard that should not be there and needs to be repaired. At 11:00 AM LPAs observed stairwell by door 7 did not have an emergency evacuation chair. Administrator stated paining was done and it was lost in the process. A new one will be ordered today 2/24/22.

Exit interview completed, deficiencies cited, civil penalty issued, copy of report and appeal rights emailed to Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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