306006019-4-22-2026-22-AS-SSAS-DTN26K-20260430170712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006019
Report Date: 04/22/2026
Date Signed: 04/22/2026 10:46:14 AM

Substantiated

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
12/20/2024 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241220151126

FACILITY NAME:	CRESCENT LANDING AT GARDEN GROVE MEMORY CARE		FACILITY NUMBER:	306006019
ADMINISTRATOR:	LOPEZ, DARLENE		FACILITY TYPE:	740
ADDRESS:	11848 VALLEY VIEW STREET		TELEPHONE:	(419) 247-2800
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	72	CENSUS: 52	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Leah Gutierrez		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Lack of supervision resulted in resident sustaining serious injuries
Lack of supervision resulted in resident sustaining multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator (AD) Leah Gutierrez and explained the reason for the visit.

During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated April 5, 2023, R1’s care plan dated March 19, 2024, R1’s charting notes dated April 24, 2023 to December 15, 2024. R1’s incident reports from November 12, 2024, and December 6, 2024. R1’s certificate of death dated December 18, 2024. R1’s hospice nursing assessment dated December 9, 2024. R1’s hospice admission form. R1’s hospice safety and fall risk assessment dated December 9, 2024. R1’s hospice medication list for December 2024. R1’s physician’s orders dated December 9, 2024. R1’s hospice plan of care dated December 9, 2024. R1’s Los Alamitos Medical Center Records dated December 6, 2024.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

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 4

Control Number 22-AS-20241220151126

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306006019
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, lack of supervision resulted in resident sustaining multiple falls, revealed the following: It was alleged, lack of supervision resulted in resident sustaining multiple falls. Resident 1 (R1) moved to the facility on April 1, 2023. R1 was diagnosed with a major neurocognitive disorder, anxiety and hyperlipidemia. R1’s physician’s report dated April 5, 2023, lists R1 as non-ambulatory and requires the use of a wheelchair. R1 was given a fall mat next to their bed at the time of move in and had a pendant placed on their wheelchair to alert staff when R1 was not in the wheelchair. 4 out of 4 staff interviewed reported that R1 was a fall risk. 4 out of 4 staff interviewed reported that the fall prevention methods were ineffective for R1. R1 sustained a fall on November 12, 2024, and on December 6, 2024. On November 12, 2024, R1 required assistance with incontinence care and needed a diaper change. Staff 1 (S1) and Staff 2 (S2) were assisting R1. The Health and Wellness Director reported that at this time staff were made aware that R1 should be changed on their bed because of their declining condition. Staff 2 reported they wanted to change R1 on their bed, but Staff 1 decided they should change R1 while they are standing and holding onto the handrail in the bathroom. Staff 2 agreed and R1 was assisted while they were standing and holding onto a handrail in the bathroom. R1 fell toward the ground, Staff 2 could not prevent the fall and R1 fell and hit their head. Staff called 911 and R1 was transported to the hospital for evaluation. Staff notified R1’s responsible party and Primary Care Physician (PCP). R1 returned later the same day with no new orders. On December 6, 2024, R1 suffered an unwitnessed fall. R1 was seen by a phlebotomist for a blood draw at approximately 10:30 am on December 6, 2024. Staff interviewed reported that the phlebotomist did not notify staff they were leaving. R1 was left unattended after the blood draw. At approximately 11:00 am Staff 3 found R1 lying next to their wheelchair with a large frontal laceration on their head. Staff 3 called 911 and R1 was transported to the hospital. Staff 3 contacted R1’s responsible party and PCP. R1 returned to the facility the same day with no new orders. There are no additional falls reported after December 6, 2024. R1 was placed on Hospice on December 9, 2024. R1 passed away on December 15, 2024, at the facility under Hospice care, cause of death, end stage senile degeneration of the brain, underlying causes: none. Other significant conditions contributing to death: none.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that lack of supervision resulted in residents sustaining multiple falls. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f).

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20241220151126

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306006019
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, lack of supervision resulted in resident sustaining serious injuries revealed the following. R1 was seen by a phlebotomist for a blood draw at approximately 10:30 am on December 6, 2024. Staff interviewed reported that the phlebotomist did not notify staff they were leaving. 2 on-duty caregivers were on break when the phlebotomist left. R1 was left unattended after the blood draw. R1 attempted to get up by themselves after being left alone in the room. At approximately 11:00 am Staff 3 found R1 lying next to their wheelchair with a large frontal laceration on their head around 7 cm long. Staff 3 called 911 and R1 was transported to the hospital. Staff 3 contacted R1’s responsible party and PCP. R1 returned to the facility the same day with no new orders. There are no additional falls reported after December 6, 2024. R1 was placed on Hospice on December 9, 2024. R1 passed away on December 15, 2024, at the facility under Hospice care, cause of death, end stage senile degeneration of the brain, underlying causes: none. Other significant conditions contributing to death: none. R1 sustained a fall on December 6, 2024, which caused a serious injury.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that lack of supervision resulted in resident sustaining serious injuries. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were discussed with and provided to facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20241220151126

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306006019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/23/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Type A: 87464(f)(1) – 87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by...	1 2 3 4 5 6 7	Licensee agrees to train care staff on CCR 87464 and to submit proof of training to LPA. Facility is closed and the above POC is NOT required.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple falls on November 12, 2024 and December 6, 2024, which caused a serious injury which poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED.	8 9 10 11 12 13 14
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	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.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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