306005257-4-11-2024-22-AS-SSAS-D48VDN-20240411162057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005257
Report Date: 04/03/2024
Date Signed: 04/11/2024 09:24:18 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240111140221

FACILITY NAME:	CRESCENDO SENIOR LIVING		FACILITY NUMBER:	306005257
ADMINISTRATOR:	VIVIAN VILLEGAS		FACILITY TYPE:	740
ADDRESS:	351 EAST PALM DRIVE		TELEPHONE:	(714) 528-4990
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	138	CENSUS: 79	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kim Mims, Wellness Director		TIME COMPLETED:	11:35 PM

ALLEGATION(S):

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A lack of supervision resulted in a resident having multiple unwitnessed falls.

Staff failed to seek medical attention for a resident who had an unwitnessed fall.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to follow up on the investigation of the two allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Wellness Director Kim Mims was notified and assisted with the visit.

An initial complaint investigation visit took place on January 16, 2024. LPA requested and obtained copies of the records maintained at the facility for resident R1. LPA conducted staff interviews with the facility Executive Director and Wellness Director during the visit.

During the follow-up visit, LPA conducted an additional staff interview. Additional witness interviews were conducted via telephone.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240111140221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CRESCENDO SENIOR LIVING	FACILITY NUMBER: 306005257
	VISIT DATE: 04/03/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that A lack of supervision resulted in a resident having multiple unwitnessed falls, the following has been concluded: R1 was an 84-years-old resident admitted to the facility on April 22, 2023. Per a review of the records maintained at the facility, R1 has a prior history of stroke resulting in lateral weakness as well as a primary diagnosis of hypertension and secondary diagnosis of diabetes. R1's pre-placement appraisal shows an assessed need to use a walker. R1 was indicated to be feeble but could get out of the walker or wheelchair unassisted. She is stated to require stand-by assistance for toileting care twice a week due to unsteady balance. Shortly before the incident reported in the present complaint, R1 sustained a fall and was taken to the Emergency Department at St. Jude where a Urinary Tract Infection was diagnosed and for which antibiotics had been prescribed. Witness interviews confirmed that since suffering a stroke, R1 was subject to syncope falls. Due to the medical history and recent events, it cannot be corroborated that the repeated falls documented resulted from a lack of supervision from facility staff.

Regarding the allegation that Staff failed to seek medical attention for a resident who had an unwitnessed fall, the following has been concluded: Earlier instances of fall incidents are demonstrated to have been reported to R1's responsible party and primary care provider with documented communications. Medical attention was sought as shown by multiple hospitalization reports dated June 2023 and December 2023. Following a shoulder fracture, physical therapy is evidenced to have been provided as well. An earlier fall in December 2023 was also assessed to necessitate medical attention and resulted in a transport to the hospital, and antibiotics prescription after an infection was diagnosed. In the instance of the falls that occurred on the night and morning of January 11, 2024, it was also found that an emergency call to the paramedics was made immediately. As a result, it cannot be corroborated that staff failed to obtain medical attention when required.

As a result, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

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