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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005257
Report Date: 05/29/2024
Date Signed: 05/29/2024 10:10:31 AM


Document Has Been Signed on 05/29/2024 10:10 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRESCENDO SENIOR LIVINGFACILITY NUMBER:
306005257
ADMINISTRATOR:VIVIAN VILLEGASFACILITY TYPE:
740
ADDRESS:351 EAST PALM DRIVETELEPHONE:
(714) 528-4990
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:138CENSUS: 78DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:KIm MimsTIME COMPLETED:
10:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on May 6, 2024. LPA met with Wellness Director (WD) Kim Mims and explained the reason for the visit.

Per Unusual Incident Report (LIC624), on May 5, 2024, at 4:50 p.m., Resident 1 (R1) was able to leave the facility unassisted and was escorted back to the facility by a neighbor.

During today’s inspection, LPA conducted an interview with WD, who confirmed R1 left the facility unassisted on May 5, 2024. Per WD, R1 is a memory care resident and it is unknown how R1 was able to leave the memory care unit.

Per Physician Reported dated February 27, 2023, R1 is diagnosed with dementia and is not able to leave the facility unassisted.

A deficiency is being cited per Title 22 Division 6 of the California Code of regulations. An exit interview was conducted and a copy of this report, and appeal rights were left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 05/29/2024 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CRESCENDO SENIOR LIVING
FACILITY NUMBER: 306005257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2024
Section Cited
CCR
1569.2(c)

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“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidence by:
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Per WD, staff training will be conducted on wandering policies and procedures. Resident activities will be increased to deter eloping and proof will be provided to LPA via email by POC date.
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Based on facility's own disclose of events, R1 was able to leave the facility unassisted and was escorted back by a neighbor, which poses an immediate health and safety risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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