435202705-3-16-2021-26-AS-SYIP-BZKPS7-20210329113349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 03/16/2021
Date Signed: 03/16/2021 03:14:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2020 and conducted by Evaluator Yatfai Ng

COMPLAINT CONTROL NUMBER: 26-AS-20200330142149

FACILITY NAME:	CRESCENT OAKS		FACILITY NUMBER:	435202705
ADMINISTRATOR:	SANDOVAL, GRACE		FACILITY TYPE:	740
ADDRESS:	147 CRESCENT AVE		TELEPHONE:	(707) 592-1157
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	44	CENSUS: 20	DATE:	03/16/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Grace Sandoval		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Facility does not have an updated emergency and disaster plan of action.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent tele-complaint investigation to deliver the investigation finding due to current COVID-19 situation. LPA virtually met with the Administrator Grace Sandoval.

On 4/1/2020, LPA interviewed the complainant regarding the allegation.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

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 26-AS-20200330142149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 03/16/2021

NARRATIVE

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An initial unannounced tele-investigation was conducted by LPA on 4/6/2020. LPA virtually toured the facility, interviewed 1 staff, and requested a copy of Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E), evacuation plan, and quarterly disaster training records. A subsequent unannounced tele-investigation was conducted by LPA on 4/13/2020. LPA virtually toured the facility, re-interviewed a staff, and obtained a copy of staff training records. From 4/23/2020 through 4/29/2020, LPA interviewed 5 additional staff.

During both virtual tours, LPA observed some residents’ rooms and dining room on the first floor were closed for renovation which was halted due to COVID-19. The temporary dining area on the second floor was observed to have 4 tables and no more than two residents at each table during meal. Facility was observed practicing social distancing during mealtime. Residents were observed sitting at least 6 feet apart. Besides the temporary dining area, staff were serving meals in residents’ rooms as well.

From 4/6/2020 through 4/16/2020, the staff who was re-interviewed stated the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) already addressed what the staff have to do when there is an emergency situation. There is 1 evacuation chair in each stairwell. Staff were trained and they had practiced using the evacuation chair.

Based on the review of Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) which was completed on 9/11/2019, the facility updated their Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) on 3/24/2020. On page 5 of Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E), it was noted the facility addressed the issue of evacuating residents in case of emergency. It states “Staff is to assist those ambulatory to safely walk down the stairs to assembly point which could be front patio or first floor lobby as both locations have a point of exit. For those non-ambulatory residents, staff is to assist them down safely using evacuation chairs located at each stairway. This action requires at least 2-person assistance.”

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200330142149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 03/16/2021

NARRATIVE

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The staff training records review noted the facility conducted fire drills and quarterly emergency and disaster plan update training on 12/10/2019 and 3/26/2020. The training topics included fire, locations of emergency shut off valves, first-aid preparedness, evacuation plan, relocation site, etc.

On 4/23/2020 through 4/29/2020, 5 staff were interviewed. 5 Out of 5 staff demonstrated their knowledge on emergency preparedness. 5 Out of 5 staff indicated that they know how to escort the non-ambulatory residents to a safe location by using the evacuation chair.

Based on observations during two tele-investigations, LPA observed two stairwells with one evacuation chair in each, which was in compliance with requirement.

Based on interviews, record review, and observation, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed and a copy of this report was emailed to Administrator for signature.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

LIC9099 (FAS) - (06/04)

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