CRESTON VILLAGE ASSISTED LIVING AND MEMORY CARE

Official classification

Type B

Official code

87470(a)(4)(A)(3)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff...shall use gloves...as specified below. (A) Gloves shall always be worn when: 3. Assisting with direct resident care... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 wears gloves per regulation and the facilities plan of operation which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator states they will provide the next level of corrective action to S1. Administrator also states that on 7/1/2026 training was provided to care staff on when to wear gloves/PPE. Administrator will email LPA training minutes, signed staff roster and corrective action taken for S1 on or before 7/21/2026.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 treated residents with dignity and respect which posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator states there will be corrective action taken for S1. Administrator states during the all staff meeting scheduled for tomorrow 7/8/2026, they will include resident rights including treating them with dignity and respect. Administrator will email LPA training minutes, signed staff roster and corrective action taken for S1, on or before 7/21/2026.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(25)

Regulation authority

CCR

What the official deficiency says

Personal Rights (a) Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when S1 stole multiple resident’s medications including narcotic medications, which posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator states S1 has not returned to the facility since 2/28/2026 and their continued employment is dependent on the outcome of this and law enforcement investigations. The locks on the med-room and refrigerator have been changed. The facility changed their policy to only store... liquid narcotic medications that a resident is actively taking. The Administrator states they will review the theft and loss program at the the next all staff meeting on 7/8/2026 and email the LPA the meeting minutes and staff roster on or before 7/10/2026.

Deadline recorded: Jul 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (a) 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 was not met as evidenced by: Based on observation and interview, the licensee did not ensure the facility was clean and sanitary which poses a potential Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator has already started checking the memory care unit more often for cleaniness and will conducted in-service training with staff on cleaning and sanitization of the facility and submit training documents and signed staff roster to LPA on or before 4/8/2026.

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(25)

Regulation authority

CCR

What the official deficiency says

Personal Rights 87468.2....residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To protection of their property from theft or loss... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when S1 stole R1’s medications, which posed an immediate health and safety risk to residents in care.

Official plan of correction

S1 was terminated 3/5/25. Administrator will create a policy addressing the residents self-custody of medication and training to review with every new and current resident who self-store medication, and as needed moving forward. The proposed policy will be emailed to LPA on 3/12/2025. A full medication audit of centrally stored medications was conducted on 3/6/2025. Administrator will email LPA documentation from the audit on 3/12/2025. Administrator will review facilities... (Continued LIC812).

Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical … provide for assistance in obtaining such care, by compliance with the following: (5) … Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met by evidence of MARs indicating medication not provided in accordance to Physicians order in February of 2024. Which poses an imminent risk to Residents in care.

Official plan of correction

Administrator agrees to conduct two hours of Medication training that includes medication initial intake, documentation, and medication distribution. Administrator will review and revise Medication Administration policy with all employees and proved LPA a copy of all staff 2 hour Medication training, as well as the facility’s current and updated medication distribution policy to LPA by 12/20/2024.

Deadline recorded: Dec 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response times with R1 that exceeded 10 minutes which poses a potential risk to residents in care.

Official plan of correction

During time of complaint investigation facility employed contract staff due to low staffing. Current staffing meet or exceed standards to meet current resident census needs.

Deadline recorded: Feb 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met by evidence of Resident and Staff interviews verifying cold meals were served on serval occasions, which poses a potential risk to residents in care.

Official plan of correction

During the time of this complaint facility employed staff that did not have adequate training. At the time this LIC9099-D was singed kitchen staff have proper training and POC is met.

Deadline recorded: Feb 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(G)

Regulation authority

CCR

What the official deficiency says

87507(g) Admission agreements shall specify ...:(G) A comprehensive description of billing and payment procedures.(H) A provision indicating that an itemized monthly statement that lists all separate charges incurred by the resident that are collected by the facility shall be provided to the resident or the resident’s representative, if any. This requirement was not met by evidence of monthly over billing of reporting parties and poses a potential danger to residents in care.

Official plan of correction

Administrator shall provided an addendum to admission agreement outlining the billing procedures with an acknowledgment from resident or resident representative of billing process. And work with Licensee to rectify the technical monthly over billing charges. Administrator will provided addendum and update to LPA by 06/09/2023.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.2(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ... shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met by evidence of photographs posted on Social Media (Facebook) of R1 and R2, where R1 and R2 both signed facility's likeness of release, not to release form which poses a potential risk to residents in care.

Official plan of correction

Administrator will provide 100% of staff a 1 hour training of resident personal rights that include instruction on regulation 87468.2. Administrator will submit list of staff that attended training and the course materials to LPA by 06/08/2023.

Deadline recorded: Jun 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a)...following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and documentation the licensee did not comply with the regulation above, residents were not being accorded dignity from a few staff at the facility which poses a potential Personal rights risk to residents in care.

Official plan of correction

Administrator agreed to hold personal rights training with staff and about inappropriate language or interactions with residents and provide staff with samples of being inappropriate on the job and Mandated reporting requirements. Send staff training documentation along with staff signatures to CCL by 3/18/2022. Civil Penalty assesed for repeat violation

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

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.

Deadline recorded: Mar 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(32)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

Facility updated equipment's and purchased a new warmer to keep food hot. POC cleared on visit.

Deadline recorded: Mar 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a)... (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews the licensee did not comply with regulation above, residents that were pressing pendants for help often were being told not to do that which poses a potential personal rights risk to residents in care.

Official plan of correction

Administrator agreed to hold personal rights training with all staff and send copy of training and staff signatures to CCL by 03/17/2022.

Deadline recorded: Mar 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(5)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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. to CCL by 02/25/2022.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

Licensee will submit memo of understanding regarding updating resident appraisals for change of condition. Submit to CCL by 03/03/2022.

Deadline recorded: Mar 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 02/25/2022 Plan of Correction Administrator agreed to have a new chair ordered and installed. Send CCL a photograph on stairwell by door 7 by 2/25/2022.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 02/25/2022 Plan of Correction 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.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 03/03/2022 Plan of Correction 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.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

...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: 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.

Official plan of correction

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.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

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.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

Licensee will submit plan how you will ensure a timely staff response time to residents’ call buttons. Submit to CCL by 02/25/2022.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

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.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: 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

Official plan of correction

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.

Deadline recorded: Mar 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the facility failed to ensure S1 and S2 were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator has agreed to immediately implement mask wearing in the facility, hold Mask/Infectious Prevention training with all staff, and provide training records with all staff signatures to CCL by 1/27/22.

Deadline recorded: Jan 27, 2022. A deadline is not proof that correction was completed.