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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005257
Report Date: 04/05/2022
Date Signed: 04/07/2022 11:55:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/29/2021 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20211129083243
FACILITY NAME:CRESCENDO SENIOR LIVINGFACILITY NUMBER:
306005257
ADMINISTRATOR:DALE WOYTEKFACILITY TYPE:
740
ADDRESS:351 EAST PALM DRIVETELEPHONE:
(714) 528-4990
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:138CENSUS: DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Lack of supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced case management visit to deliver amended investigation findings to the facility. Licensing Program Analyst (LPA) Norman Woodridge conducted an unannounced visit to the facility and met with Administrator (AD) Dale Woytek to follow up regarding compliant that the facility provided lack of supervision which lead to a resident wandering away from the facility.
The investigation revealed the following:
It was determined that facility staff did briefly fail to keep sight of resident which resulted in the resident being unsupervised for a period of time. This information was corroborated by statements made in interviews conducted with four out of four interviewees.

The original report delivered was missing its LIC9099-D component regarding the deficiencies substantiated, which is now being provided to licensee. LPA Saborit-Guasch conducted an exit interview and provided a copy of this report along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 2
Control Number 22-AS-20211129083243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/06/2022
Section Cited
HSC
1569.2(c)
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Health and Safety Code section 1569.2(c) provides: (c) "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.
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Facility will ensure adequate supervision for residents, especially those with a history of wandering behavior
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This requirement was not met as evidenced by the determination that facility staff did briefly fail to keep sight of resident which resulted in the resident being unsupervised for a period of time, as corroborated by statements made in interviews conducted by LPA.
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2