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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006473
Report Date: 02/23/2026
Date Signed: 02/23/2026 04:59:09 PM

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
02/18/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260218185737
FACILITY NAME:CRESCENDO SENIOR LIVINGFACILITY NUMBER:
306006473
ADMINISTRATOR:GALAL, LAURELFACILITY TYPE:
740
ADDRESS:351 EAST PALM DRIVETELEPHONE:
(714) 528-4990
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:210CENSUS: 88DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director of Wellness Alex GutierrezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff is mismanaging resident's medications.
Staff does not provide adequate supervision resulting in resident sustaining multiple falls.
INVESTIGATION FINDINGS:
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On February 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Director of Wellness Alex Gutierrez was notified via telephone and later arrived to assist with the inspection.

During the course of the investigation, LPA conducted resident interviews, staff interviews, reviewed medication and medication administration records, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff is mismanaging resident's medications, the following has been concluded: It was alleged that staff are mismanaging Resident #1 (R1) medication. LPA reviewed the medications, the prescribed orders, and the medication administration records for R1. LPA observed that staff were providing the routine medications to R1 according to his prescribed orders, as per regulations. However, LPA observed the facility did not physically have R1's prescribed Hydroxyzine Pam 50 MG medication and Systane Balance 0.6% eye drops, which are as needed medications. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
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 3
Control Number 22-AS-20260218185737
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: 306006473
VISIT DATE: 02/23/2026
NARRATIVE
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LPA observed that R1's Hydroxyzine Pam 50 MG medication was prescribed on January 29, 2026. LPA observed that R1's Systane Balance 0.6% eye drops were prescribed on December 12, 2025. LPA reviewed R1's medication orders as of February 23, 2026, which confirmed both medications still had active orders. Two staff present during the visit confirmed the facility did not have R1's prescribed Hydroxyzine Pam 50 MG medication or his Systane Balance 0.6% eye drops physically present, or available to R1 if they were needed. Additionally, LPA observed the facility did not have discontinue orders on file for these two as needed medications for R1, and therefore, these medications should be available at the facility. LPA attempted to conduct an interview with R1, however, R1 was unable to be qualified for an interview. LPA attempted to conduct an additional five resident interviews. However, none of the residents were able to be qualified for an interview.

Regarding the allegation, staff does not provide adequate supervision resulting in resident sustaining multiple falls, the following has been concluded: It was alleged that staff does not provide adequate supervision resulting in R1 sustaining multiple falls. LPA reviewed R1's records. LPA observed that R1 was admitted to the facility on December 12, 2025. LPA reviewed R1's resident assessment dated November 15, 2025, which states that R1 is a fall concern. LPA reviewed R1's patient visit summary dated February 13, 2026, which stated that R1 has a history of repeated falls, and is an increased risk for falls due to confusion, muscle weakness, and immobility. LPA observed that R1 has sustained four documented falls while at the facility, including on February 8, February 10, and twice on February 12, 2026. LPA observed that the fall R1 sustained on February 8, 2026, required R1 to be sent out to the hospital due to multiple skin lacerations, as well as R1 refusing first aid treatment from staff. LPA observed the three other falls did not require R1 to be sent to the hospital, however, R1 sustained skin tears as a result of the falls. LPA conducted four staff interviews. Four out of the four staff interviewed confirmed R1 has sustained multiple falls while at the facility. LPA observed that there are no re-assessments on file for R1, despite having four documented fall at the facility, to determine if there was a change in condition or if more supervision is necessary. Furthermore, there are no documented fall prevention techniques in place despite R1 having four documents falls at the facility between February 8, and February 12, 2026.

Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Director of Wellness Alex Gutierrez. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260218185737
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: 306006473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2026
Section Cited
CCR
87465(b)
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87465 Incidental Medical and Dental Care: (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a .. nonprescription PRN medication, facility staff shall be permitted to assist the resident..
This requirement was not evidenced by:
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The Director of Wellness stated that he will order the two PRN medications for Resident #1, or obtain discontinue orders for those medications. The Director of Wellness agreed to provide LPA proof that the PRN medications are at the facility, or dicontinued, via email or fax by POC date.
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Based on records reviewed and interviews conducted, the Licensee did not ensure that all presribed PRN medications were present at the facility, and available to Resident #1 if needed. This poses a potential health, safety, and personal rights risk to persons in care.
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Type B
03/06/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not evidenced by:
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The Director of Wellness stated that he will create a care plan for Resident #1 to address his frequent falls. The Director of Wellness agreed to provide LPA the care plan for Resident #1 via email or fax by POC date.
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Based on records reviewed and interviews conducted, the Licensee did not ensure that Resident #1 has sufficient supervision, or a sufficent care plan, to address his frequent falls at the facility. This poses a potential health, safety, and personal rights 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3