<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850010
Report Date: 03/10/2022
Date Signed: 03/11/2022 11:29:35 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
10/09/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20201009102940
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: 76DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident wandered away from the facility
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 investigation. LPA met with Administrator Cheryl Marsh at 11:15 AM and explained the purpose of the visit.

LPA Jefrries conducted the initial investigation on 10/14/2020 from 8:16 aM- 10:45 Am and gather documentation. LPA reviewed documentation from 11:30 am-1:00 PM. LPA conducted interviews with staff and residents from 1:00 PM-5:30 PM. LPA toured the kitchen, dining room, refrigerator, freezers, and pantry food supply.

On the allegation: Resident wandered away from the facility. LPA reviewed incident report from facility. On 07/20/2020 R1 was able to elope from the memory care unit. R1 was given a ride to family home. 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: 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
10/09/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20201009102940

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: 76DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to report incident
Food is of poor quality
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 investigation. LPA met with Administrator Cheryl Marsh at 11:15 AM and explained the purpose of the visit.

LPA Jefrries conducted the initial investigation on 10/14/2020 from 8:16 AM- 10:45 AM and gather documentation.

LPA De Leon reviewed documentation from 11:30 am-1:00 PM. LPA conducted interviews with staff and residents from 1:00 PM-5:30 PM. LPA toured the kitchen, dining room, refrigerator, freezers, and pantry food supply.

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: 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: 2 of 5
Control Number 29-AS-20201009102940
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
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On the allegation: Facility staff failed to report incident. LPA reviewed documentation of an incident report regarding R1 wandering away from the facility. The incident happened on 07/20/2020 and an incident report was sent to CCL on 07/24/2020. Based on the evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Food is poor in quality. LPA De Leon toured the kitchen and food supply which meets the food service requirements. Residents interviews revealed the food is of good quality but is not prepared and over cooked at times. The food was being served to residents rooms and was served cold which was cited on 29-AS-20200901154537. Based on the evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (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: 3 of 5
Control Number 29-AS-20201009102940
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
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 R1's family called facility and reported R1 being brought home by an unknown person that found R1 walking. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (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-20201009102940
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 A
03/16/2022
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidneced by:
1
2
3
4
5
6
7
Administrator agreed to have safety trianing with staff in memery care regarding wandering. Send training records and staff signatures to CCL by 03/11/2022.
8
9
10
11
12
13
14
Based on documentation the licensee did not comply R1 was able to elope undected and wander away from facility which poses an immediate safety risk to reisdents 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (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