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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 02/24/2022
Date Signed: 02/24/2022 03:45:48 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
09/21/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200921120015
FACILITY NAME:CRESTON VILLAGE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:MAYFIELD, MICHAELFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:130CENSUS: 75DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
Resident’s diapering needs were not being met
Staff not responding to residents call button in a timely manner
Staff not providing appropriate bed accommodations for resident
Facility is not kept free of pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA’s) Rachael De Leon and Jeannette Olson conducted a subsequent complaint visit to deliver findings of the allegations. The initial visit was conducted on 09/22/2020 by LPA Mark Jeffries. During today’s visit, LPA’s De Leon and Olson met with Administrator Cheryl Marsh and explained the purpose of the visit.

On 09/21/2020, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision - Resident #1 (R1) fell and sustained multiple injuries. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Elisia Rippe. The remaining allegations above were investigated by LPA’s Jeffries and De Leon.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
NARRATIVE
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On 09/22/2020, from 11:35 a.m. to 1:35 p.m., LPA Jeffries conducted the initial complaint visit telephonically with Executive Director/Administrator, Michael Mayfield. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted telephonically and through FaceTime. LPA Jeffries conducted a physical plant tour from 11:35 am to 1:35 pm and requested copies of pertinent documents relevant to the investigation and took photographs of Resident 1’s (R1) room.

During Investigator Rippe’s investigation, interviews were conducted, medical reports were obtained and reviewed. Investigator Rippe conducted interviews with R1’s responsible party on 10/06/2020 at 7:25 a.m. and 12:20 p.m.; and with R1 at 12:02 p.m.; with staff on 10/15/2020 at 1:00 p.m.; with Regional Director of Operations on 10/20/2020 at 3:16 p.m. and on 10/22/2020 at 10:07 a.m.; with staff on 10/22/2020 from 11:26 a.m. to 12:47 p.m.; with the Executive Director/Administrator on 10/29/2020 at 8:56 a.m.; with staff on 11/04/2020 at 12:57 p.m.; and with staff on 11/13/2020 from 8:37 a.m. to 3:21 p.m.

On the allegation: Resident sustained multiple pressure injuries while in care - The Wilshire Home Health (HH) reports for September 2020 stated that R1 had a stage two pressure injury on right buttocks, a stage one pressure injury on sacrum, and a stage one pressure injury on coccyx area. According to the last report from HH on 09/29/2020 the pressure injuries has been staged as a 3 by a Medical Doctor. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Resident’s diapering needs were not being met- HH records revealed on 08/25/2020 R1 was assisted in brief change during transfer to toilet resident was soiled with stool and HH staff held a conference with the facility staff Medication Technicians (MT) and Resident Assistants (RA) about R1 not being aware of loss of control and asked staff to visually inspect briefs for adequate hygiene and infection process.
Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
NARRATIVE
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Witness 1's (W1) interview revealed R1 was soaked with BM's on every visiit. HH reports for the beginning of September 2020 stated R1 had a stage two pressure injury on right buttocks, stage one pressure injuries on sacrum and coccyx area as of 09/29/2020 the pressure injuries were not healing and had been staged as a 3 by MD. Staff interviews revealed 3/7 staff stated R1 was found soiled on several different occasions. Based on the information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Staff not responding to residents call button in a timely manner – The facility provided copies of the call log for R1. From the time period of 09/04/2020 to 09/06/2020, the staff response time to R1’s call button ranged from 9 to 25 minutes, which indicates an untimely staff response. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Staff not providing appropriate bed accommodations for resident – Staff admitted moving R1’s mattress to the floor to prevent injury to R1 falling out of bed. There was no Dr. order or letter of support from the responsible party to move the mattress to the floor. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time.


On the allegation: Facility is not kept free of pests- Based on LPA Jeffries observation, tour of the facility with the Administrator and 12 photographs LPA took of room 111 showed bugs, dead bugs, and spider webs present. Administrator confirmed this to LPA Jeffries that there were cobwebs on the curtains and window seals. Based on the evidence the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited
CCR
87466
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...residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided...This requirement is not met as evidenced by:
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Licensee will submit memo of understanding on how facility will ensure residents will be observed for change of conditions and a plan on pressure injuries prevention and care. Submit to CCL by 02/25/2022.
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Based on medical reports and interviews, R1 had multiple pressure injuries observed but not reported by the Licensee, which posed an immediate health and safety risk to residents in care.
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Type A
02/25/2022
Section Cited
CCR
87625(b)(3)
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(b)...(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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Administrator Review resident records for incontinence, train all staff on caring for Incontinence residents and provide proof of training, staff signatures on trianing records to CCL by 02/25/2022.
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Based on medical reports and interviews the Licensee did not ensure the R1’s diapering needs we are being met which poses an immediate health and safety 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: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited
CCR
87303(i)(1)(B)
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(i)…(1) shall have a signal system which shall…(B)…produce an auditory signal at the living unit loud enough to summon staff.
This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure a timely staff response time to residents’ call buttons. Submit to CCL by 02/25/2022.
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Based on review of call log 09/04/2020 to 09/06/2020, staff response time to R1’s call button was from 9 minutes to 25 minutes, which posed an immediate health and safety risk to residents in care.
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Type A
02/25/2022
Section Cited
CCR
87307(a)(3)(A)
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(a)...(3)...(A)A bed for each resident… Each bed shall be equipped with good springs, a clean and comfortable mattress…This requirement is not met as evidenced by:
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Licensee will submit memo of understanding regarding providing an appropriate bed for residents unless modification is prescribed by a physician. Submit to CCL by 02/25/2022.
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Based on interviews, staff admitted moving R1’s mattress to the floor to prevent injury to R1 falling out of bed, which posed an immediate health and safety 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: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2022
Section Cited
CCR
87303(a)
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(a)The facility shall be clean, safe, sanitary and in good repair at all times. ...safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee agreed to have housekeeping clean all rooms making sure to check for bugs, cobwebs, curtains, windows, and dirt from window seals. Send a complete roster with rooms cleaned.
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Based on Observation and photographs the licensee did not comply with the regulation above R1’s room was found with bugs and dead bugs all over the floors, cobwebs in the windows and curtains and dirt in window seals which poses a potential 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: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
09/21/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200921120015

FACILITY NAME:CRESTON VILLAGE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:MAYFIELD, MICHAELFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:130CENSUS: 75DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident fell sustaining multiple fractures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA's) Rachael De Leon and Jeannette Olson conducted a subsequent complaint visit to deliver findings for the above allegation. The initial visit was conducted on 09/22/2020 by LPA Mark Jeffries. During today’s visit, LPA De Leon and Olson met with Cheryl Marsh and explained the reason for the visit.

On 09/21/2020, the Department received a complaint regarding an allegation that Resident #1 (R1) fell and sustained multiple injuries. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Elisia Rippe.

Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
NARRATIVE
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On 09/22/2020, from 11:35 a.m. to 1:35 p.m., LPA Jeffries conducted the initial complaint visit telephonically with Executive Director/Administrator, Michael Mayfield. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted telephonically and through FaceTime. LPA Jeffries conducted a physical plant tour from 11:35 am to 1:35 pm and requested copies of pertinent documents relevant to the investigation. The physician’s report dated 08/23/2018.

Investigator Rippe conducted interviews with R1’s responsible party on 10/06/2020 at 7:25 a.m. and 12:20 p.m.; and with R1 at 12:02 p.m.; with staff on 10/15/2020 at 1:00 p.m.; with Regional Director of Operations on 10/20/2020 at 3:16 p.m. and on 10/22/202 at 10:07 a.m.; with staff on 10/22/2020 from 11:26 a.m. to 12:47 p.m.; with the Executive Director/Administrator on 10/29/2020 at 8:56 a.m.; with staff on 11/04/2020 at 12:57 p.m.; and with staff on 11/13/2020 from 8:37 a.m. to 3:21 p.m.

On 07/02/2020 at 8:30 p.m., R1 was getting coffee in R1’s assisted living apartment and slipped on some coffee that had spilled on the floor. R1 was ambulatory and able to walk using a walker on own prior to July 2020. R1 was taken to Twin Cities Hospital, where an x-ray was taken and noted that R1’s right femur was fractured. R1 had open reduction and internal fixation (ORIF) surgery to place a rod in the femur and was then transferred to Mission View Rehabilitation from 07/08/2020 to 07/29/2020. R1 returned to Creston Village Assisted Living on 07/29/2020. R1 was not able to walk and was in a wheelchair. R1 returned to the same assisted living apartment. R1 required more care upon return to the facility. The administrator denied telling R1’s responsible party there would be two staff with R1 at all times. Staff stated they checked on R1 every 30 to 60 minutes. Staff stated when R1 returned from the rehab facility, R1 would throw self out of bed and onto the floor and hid pendant from staff. Due to these behaviors, staff moved R1’s mattress to the floor. Per Home Health notes, R1 had 3 falls since returning from the rehab facility. R1 stated to the Home Health nurse that R1 was intentionally throwing self out of bed in order to cause self-harm.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20200921120015
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: 02/24/2022
NARRATIVE
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On 09/05/2020, R1 was found on the floor of R1’s assisted living apartment, was taken to Twin Cities Community Hospital and diagnosed with a left proximal humerus fracture. Hospital notes state “patient fell out of bed onto floor, has a history of falling out of bed, patient mental status has been declining since recent rehab admission after leg fracture 2 months ago”. During the visit, R1 was also diagnosed with a urinary tract infection (UTI).

Investigator Rippe requested and reviewed medical records pertinent to the investigation and conducted interviews. R1 admitted to rolling out of bed and going to the hospital while living at the facility. R1 was unable to provide any further details. The former Executive Director/Administrator, Michael Mayfield, gave the approval for R1 to return to the facility from the skilled nursing facility. He did not promise R1’s responsible party that there would be two staff members with R1 at all times. Information provided through interviews found that R1 would throw self out of bed and onto the floor, which led staff to place mattress on floor to prevent injury. Investigator Rippe found no evidence of neglect or lack of supervision regarding R1’s care. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
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
LIC9099 (FAS) - (06/04)
Page: 9 of 9