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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006473
Report Date: 09/12/2026
Date Signed: 09/12/2026 11:25:47 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
02/24/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260224164536
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: 124DATE:
09/12/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vanessa CabanasTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Resident sustained unexplained injuries due to staff neglect or abuse while in care.
Facility failed to seek timely medical care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, the Department toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as hospital records. Regarding the allegations that resident sustained unexplained injuries due to staff neglect or abuse while in care and facility failed to seek timely medical care, the investigation revealed the following: Resident 1 (R1) was admitted into the facility on November 25, 2025. Per physician report dated September 10, 2025, R1 is diagnosed with Dementia and requires supervision from staff for ambulation. Needs and Services Plan dated November 26, 2025, indicates resident is a full assist with ambulation, a fall risk and will be checked every two hours. A review of R1’s records revealed multiple falls while in care at the facility. On January 05, 2026, facility reported to the Department via Unusual Incident Report (UIR) that R1 had an unwitnessed fall and was discovered by staff at approximately 2306 on January 02, 2026. CONT ON LIC 9099C DATED 09/12/2026
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2026
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-20260224164536
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: 306006473
VISIT DATE: 09/12/2026
NARRATIVE
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The resident had a skin tear to the left elbow and a bruise on the left shoulder. First aid was applied and the resident was put back in bed. There was no medical attention sought despite multiple staff interviews confirming R1 was observed to be in pain. R1 did not receive medical attention until their Responsible Party requested an X-ray on January 03, 2026, after they were observed not walking at baseline. The X-ray occurred on January 05, 2026, and the results came back on January 07, 2026, revealing the resident had a fracture of the left hip. Hospital records show the resident was diagnosed with Left displaced femoral neck fracture and underwent surgery on January 08, 2026. On February 21, 2026, R1 was observed to be in pain by staff after having a witnessed fall where the resident fell back in the wheelchair and hit the resident’s head. Facility did not call 911, rather a call was made to Hospice who stated there was a comfort kit for pain as needed. While visiting the resident that same day, the Responsible Party noticed the resident screamed when the resident’s leg was touched. The Responsible Party contacted the resident’s physician who insisted on obtaining an X-ray. Responsible Party stated the same hip was broken a second time but R1 was no longer a candidate for surgery.
Five out of five staff interviewed stated that the resident was a fall risk and had numerous unwitnessed falls, usually at night. Staff indicated that the resident had a fall mat and was a two-person assist. The former Wellness Director stated no fall risk assessments had been completed for the resident during her employment at the facility nor is able to recall if a pain assessment was done on the resident. Besides the fall mat, facility took no further precautions to prevent the resident from falling.
The investigation revealed that R1 was identified as a high fall risk and had several documented falls, resulting in bumps, bruises, lacerations and fractures throughout R1’s residency at the facility. The facility was aware that R1 had experienced several unwitnessed falls and failed to implement necessary measures to meet R1’s needs and seek timely medical attention resulting in a five day delay of medical attention for fracture sustained in care. A pattern of continued falls by R1, together with multiple injuries, implies that the resident is at very high risk of falling. While the facility implemented an intervention that aligned with safety measures, the persistent frequency and escalation in injury demonstrated inadequate development and implementation of supervision to meet the resident’s actual safety needs. Based on interviews conducted and record review, the allegations are deemed substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).
An exit interview was conducted and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20260224164536
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: 306006473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2026
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This req is not met as evidenced by:
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Licensee to provide a written plan outlining how to adress residents with fall risk and forward proof to LPA by POC date.
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Based on interviews conducted and record review, Licensee failed to ensure R1 re-assessments and implement necessary interventions to prevent repeated falls resulting in R1 sustaining multiple fractures. This poses an immediate health and safety risk to residents in care.
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Type A
09/13/2026
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This req is not met as evidenced by:
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Licensee to conduct an in-service on responding to emergencies and forward proof to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure 911 was called after R1 had fallen and was observed to be in pain resulting in a five day delay of medical attention for fracture. This poses an immediate health and safety risk to residents 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3