306005257-1-10-2022-22-AS-MVAO-CG4R45-20220707124059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005257
Report Date: 01/10/2022
Date Signed: 01/10/2022 05:17:39 PM

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
12/31/2021 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211231164336

FACILITY NAME:	CRESCENDO SENIOR LIVING		FACILITY NUMBER:	306005257
ADMINISTRATOR:	DALE WOYTEK		FACILITY TYPE:	740
ADDRESS:	351 EAST PALM DRIVE		TELEPHONE:	(714) 528-4990
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	138	CENSUS: 82	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Robert Jakini, Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility elevator is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced visit to the facility on this day for the purpose of conducting a complaint investigation regarding the allegation noted above. LPA met with Executive Director, Robert Jakini, Executive Director.

LPA Chin spoke to Robert Jakini, Executive Director and he admitted that a representative from Amtech Elevator Services came today, 1/10/2021 and fixed the elevator as it was broken. Mr. Jakini provided seven receipts in which Amtech Elevator Services has been fixing the elevator since October 10, 2021, November 11, 2021, December 28, 2021, December 31, 2021, and January 10, 2021 and two other maintenance receipts. There is only one elevator in the main building. Mr. Jakini and LPA Chin went to observe the elevator and a sign in front of the elevator indicated, "Out of Order." Mr. Jakini indicated that the elevator is in limited in use. There was an incident in which someone was stuck in the elevator and the elevator need to be pried open. There are no incident reports in which the facility reported to the licensing office that the elevator was broken several times. (Continued on LIC 809C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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-20211231164336

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: 01/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 01/10/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation 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, interviews, record review, the	1 2 3 4 5 6 7	Robert Jakini, ED provided receipts as proof. He also will relocate any of the four to fix residents who are interested in moving to the first floor since they are using a wheelchair.
	8 9 10 11 12 13 14	elevator has been broken several times since October 2021. Today, 1/10/2021, the elevator was repaired as it was broken. This poses a potential risk to the health & safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20211231164336

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
	VISIT DATE: 01/10/2022

NARRATIVE

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Mr. Jakini stated that meals are being delivered to those who are unable to walk down the stairs from the second floor. As of today, Mr. Jakini stated that four to five residents were provided the choice to move down to the first floor. There are several resident on the second floor who are in wheelchairs. It makes it difficult for these resident when the sole elevator in the building is not working properly.

Based on LPA's observations, conducted interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiency is a violation of Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted along with appeal rights were provided and a copy of this report was left.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

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