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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850010
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:00:18 PM

Document Has Been Signed on 02/24/2022 04:00 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 CAREFACILITY NUMBER:
405850010
ADMINISTRATOR:CHERYL MARSHFACILITY TYPE:
740
ADDRESS:1919 CRESTON ROADTELEPHONE:
(805) 239-1313
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 130CENSUS: 75DATE:
02/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cheryl Marsh, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rachael De Leon conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20200921120015). LPA De Leon met with Cheryl Marsh. The purpose todays visit is to issue citations for deficiencies observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20200921120015, the following deficiencies were observed:

R1’s Physician Report was dated 08/23/18. R1 was noted to have “Baseline Dementia” during a 09/05/20 ER visit. There was no updated Physician Report provided due to R1’s change of condition.

R1’s Resident Evaluation was updated 08/03/2020 – there are no signatures/dates from appropriate parties on the updated evaluation. R1’s evaluation was not updated when R1 began having behaviors of throwing self out of bed to cause self-harm and was diagnosed with “Baseline Dementia” during a 09/05/2020 ER visit.

Resident #1 (R1) had a fall on 7/31/20 and 09/05/20. The Wilshire Home Health reports for September 2020 indicate 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. R1 was diagnosed with a Urinary Tract Infection (UTI) on 09/05/21. No Special Incident Reports (SIRs) were submitted to Community Care Licensing (CCL).

Exit interview conducted, deficiencies cited, copy of report and appeal rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
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 04:00 PM - It Cannot Be Edited


Created By: Rachael De Leon On 02/24/2022 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87705(5)

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MedicalAssessment,...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Adminitrator agreed to review regualtion 87705 andl submit a memo of understanding of the requirements for providing updated medical assessments for residents when there is a change of condition.
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Based on Record Review the licensee did not comply R1 had a change of condition, No annual medical assessment and was diagnosed with “Baseline Dementia” during a 09/05/2020 ER visit, which posed an immediate health and safety risk to residents in care.
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to CCL by 02/25/2022.
Type B
03/03/2022
Section Cited
CCR87463(a)

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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition….This requirement was not met as evidenced by:
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Licensee will submit memo of understanding regarding updating resident appraisals for change of condition. Submit to CCL by 03/03/2022.
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Based on interviews and documentation review, R1’s Resident Evaluation was not updated to reflect R1’s change of condition, which posed a potential 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 Burley
LICENSING EVALUATOR NAME:Rachael De Leon
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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