405850010-3-11-2022-29-AS-KBUY-CCLPDR-20220317111358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 03/10/2022
Date Signed: 03/11/2022 11:33:54 AM

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
09/01/2020 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20200901154537

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR:	MAYFIELD, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	130	CENSUS: 76	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Cheryl Marsh, Administrator		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Food is served cold.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Administrator Cheryl Marsh and explained the purpose of the visit.

LPA Jeffries conducted the initial investigation on 09/02/2020 from 7:59 am- 2:00 pm. LPA Jeffries made a subsequent visit on 04/15/2021 from 7:06 am-12:11pm. LPA interviewed Residents (R1-R15) from 7:05am through 10:00am, Head Chef at 7:20am, Administrator at 8:29am and Staff (S1-S3) from 9:45am-10:45am. LPA toured the kitchen with Chef, collected photographs of kitchen from 7:10am through 9:20am. LPA observed morning food service meals for entire census on this day.

Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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 5

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
09/01/2020 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20200901154537

FACILITY NAME:	CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	405850010
ADMINISTRATOR:	MAYFIELD, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1919 CRESTON ROAD		TELEPHONE:	(805) 239-1313
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	130	CENSUS: 76	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Cheryl Marsh, Administrator		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

1
2
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7
8
9

Facility's food is not of good quality.
Licensee is not providing nutritious food.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Administrator Cheryl Marsh and explained the purpose of the visit.

LPA Jeffries conducted the initial investigation on 09/02/2020 from 7:59 am- 2:00 PM. LPA Jeffries made a subsequent visit on 04/15/2021 from 7:06 am-12:11pm. LPA interviewed Residents (R1-R15) from 7:05am through 10:00am, Head Chef at 7:20am, Administrator at 8:29am and Staff (S1-S3) from 9:45am-10:45am. LPA toured the kitchen with Chef, collected photographs of kitchen from 7:10am through 9:20am. LPA observed morning food service meals for entire census on this day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20200901154537

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: 03/10/2022

NARRATIVE

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During the investigation process on this day, LPA reviewed resident files for meal plans and doctors orders pertaining to meal plans and functional capabilities as it relates to food services.

LPA De Leon conducted interviews with staff and residents from 1:00 PM- 5:00pm. LPA toured the facility Kitchen, dining room and food supply at 1:35pm.

On the allegation: Facility's food is not of good quality. LPA Interviewed staff and residents which revealed the food is of good quality but not always cooked well, over cooked at times and sometimes tasted bland. Facility invoices show adequate and quality food being purchased regularly. LPA Jeffries took photographs of quality foods. LPA De Leon observed quality food in refrigerator, freezer and walk in pantries. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Licensee is not providing nutritious food. LPA interviewed staff and residents which revealed the food is nutritious. The facility invoices, tour of kitchen, photographs of the meals all show food with nutritional value. The facility meets regulation requirements for food service. Based on the evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed the Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20200901154537

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: 03/10/2022

NARRATIVE

1
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3
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32

During the investigation process on this day, LPA reviewed resident files for meal plans and doctors orders pertaining to meal plans and functional capabilities as it relates to food services.

LPA De Leon conducted interviews with staff and residents from 1:00 PM- 5:00pm. LPA toured the facility Kitchen, dining room and food supply at 1:35pm.

On the allegation: Food is served cold. LPA's interviewed staff and residents which revealed during 2020, quarantined and isolation periods the food served to the residents rooms was cold. Staff interviews reveal numerous complaints from residents at the time the food was arriving cold. The facility made adjustments and purchased additional warming equipment to help with the complaints that were coming in. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20200901154537

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: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2022 Section Cited CCR 87555(b)(32)	1 2 3 4 5 6 7	(32) Equipment or appropriate size and type shall be provided for the storage, preparation and service of food and for sanitizing utensils and tableware, and shall be well maintained. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility updated equipment's and purchased a new warmer to keep food hot. POC cleared on visit.
	8 9 10 11 12 13 14	Based on interviews the licensee did not comply with the above regulation as food was not being served hot which poses a potential health and personal rights risk to residents in care.	8 9 10 11 12 13 14
	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: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5