435202705-7-31-2025-26-AS-ACON-DLJVU8-20250915164419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 07/31/2025
Date Signed: 07/31/2025 01:17:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/23/2025 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20250523161929

FACILITY NAME:	CRESCENT OAKS		FACILITY NUMBER:	435202705
ADMINISTRATOR:	JOSHUA LAMBENGCO		FACILITY TYPE:	740
ADDRESS:	147 CRESCENT AVE		TELEPHONE:	(408) 730-4004
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	44	CENSUS: 39	DATE:	07/31/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Bernadette Kang		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not assist resident with feeding resulting in weight loss

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On July31, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Resident Care Coordinator (RCC), Bernadette Kang. The LPA disclosed the purpose of the visit.

On 05/23/2025, the department received a complaint with the above one (1) allegation. On 5/28/2025, the department conducted initial investigations at the facility.

Regarding the allegation ‘Facility staff did not assist resident with feeding resulting in weight loss’, the Reporting Party (RP) alleged that the R1 was not given food, R1 was hungry, and R1 had been losing weight.

On 05/28/2025 and 07/08/2025, LPA interviewed three (3) staff members (S2, S5, and S6), and three (3) residents (R3, R4, and R5).

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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 5

Control Number 26-AS-20250523161929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 07/31/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S2 stated that there had been no service plan in place to provide feeding assistance to R1 when R1 first moved into the facility; however, staff still assisted R1 with feeding. S2 stated that the service plan was updated on April 27, 2025, to include feeding assistance for R1, but POA did not sign the updated plan. S2 further stated that on 04/27/2025, when R1 felt dizzy, R1 had finished their dinner. Snacks were provided between 6:30 and 7:00 PM and were available to residents both day and night. S5 stated that they had assisted R1 with feeding during breakfast and lunch, as well as with showering and changing clothes. S5 reported that R1 ate pureed vegetables and fruits, along with yogurt, served on a three-compartment plate. R1 ate very slowly, and some food would spill from their mouth, but R1 would finish their meals. S5 stated they were responsible for feeding two residents, including R1, during mealtimes in the dining room. S6 stated that they worked the evening shift and would bring R1 to the dining room to feed dinner, which consisted of pureed foods, along with assisting one other resident at the same time. S6 reported that R1’s meals typically included items like yogurt, mashed banana, and dessert. R1 ate slowly, and some food would spill while R1 was eating, but R1 would finish the entire plate within 30 to 35 minutes. S6 stated that R1 never requested any snacks or additional food after dinner. S6 further stated that they had fed R1 dinner on the day 911 was called. S6 recalled that after dinner, R1 went upstairs, and it was R1’s roommate (R5) who pressed the call button when R1 began feeling unwell.

R3 stated that they had received three meals a day and snacks in between. R4 stated that they ate breakfast and dinner but did not eat lunch or snacks frequently. R5 stated that they remembered R1 as their roommate. R5 further stated that R1 appeared to have difficulty with swallowing, as food would often spill from R1’s mouth, and staff assisted R1 with eating mashed food. R5 stated that R1 experienced a heart attack and was sent to the hospital.

On 05/27/2025, LPA interviewed R1’s Power of Attorney (POA) / Reporting Party (RP). POA stated that they had observed signs of neglect in December 2024. POA reported that R1 required one-on-one assistance with feeding, but there were no staff available to assist R1 with feeding whenever they visited the facility. POA stated that feeding assistance was the primary reason for admitting R1 to the facility. POA further stated that they did not have any documentation confirming that R1 would receive one-on-one feeding assistance at the facility or outlining any specific feeding arrangements that had been agreed upon. However, POA mentioned they had informed the facility’s sales coordinator, who was no longer employed there, that R1 needed to be fed. POA also stated that R1’s Primary Care Physician (PCP) had expressed concerns about R1’s weight loss and had indicated PCP would speak to the facility regarding R1’s feeding needs.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20250523161929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 07/31/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 07/08/2025, LPA interviewed R1’s Primary Care Physician (PCP). PCP stated that R1 had been diagnosed with ALS and that they had been seeing R1 every two weeks since R1 became their patient in January 2025. The PCP stated that R1 was on a pureed diet and required staff assistance with eating. The PCP further stated that during their visits to the facility, they observed on multiple occasions that R1 was receiving assistance from staff during meals, along with other residents. The PCP noted that staff at the RCFE had to take turns assisting residents with meals, as one-on-one service was not provided unless arranged through private pay. The PCP further stated that R1’s deterioration was consistent with the progression of ALS and not related to the food provided. R1 was receiving supplemental nutrition, such as Ensure. The PCP explained that muscle wasting was a symptom of ALS and that maintaining weight was difficult. The PCP emphasized that R1’s condition was due to a neurodegenerative disorder and not because the staff was not assisting R1 with the food.

On 07/11/2025, POA emailed LPA an image of text messages written in Tagalog. POA claimed to have received these messages from R1. POA stated that the English translation of the messages was as follows: staff were rude to R1; R1 had asked staff to warm up an Ensure drink (which had been approved by R1’s PCP), but staff threw it away instead. POA further stated that they had ordered the Ensure drinks through Amazon and had them delivered directly to the facility. However, each time POA visited R1, they were unaware of where the Ensure drinks were being stored. POA further stated that staff wanted R1 to hurry and finish their meals. POA noted that R1 had ALS and experienced difficulty eating independently. POA stated that staff would remove R1’s food when R1 was unable to finish within a certain time, and R1 would ask staff, “Where is my food?” POA also stated that R1 mentioned there was nothing they could do about the situation, but expressed feeling weak.

On 07/15/2025, LPA reviewed the dates of the text message images. The messages were dated December 18, 2024, December 24, 2024, and March 29, 2025. Upon review of R1’s order for nutritional supplements, LPA noted that R1’s Primary Care Physician (PCP) had written the Ensure order on 04/15/2025.

On 07/17/2025, S1 sent an email to the LPA, which included a screenshot of text messages that S1 had sent to the facility’s care team. The first part of the text messages indicated that R1 had been out of the facility with their POA from 12/19/2024 and returned on 12/26/2024, and had again left with their POA on 02/15/2025 and returned on 02/21/2025. The second part of the text messages indicated that on 02/05/2025, S1 had instructed the kitchen chef, per R1’s request, to prepare two (2) pureed hard-boiled eggs for breakfast and dinner and to offer a smoothie to R1 as a snack. S1 stated they always met the food needs and requests of R1.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20250523161929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 07/31/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/04/2025, LPA reviewed R1’s LIC 602 Physician’s Report. Based on the LPA’s review, the report had been signed by R1’s physician on 10/24/2024, and the section indicating ‘Able to Feed Self’ had been marked ‘Yes.’

On 06/04/2025, LPA reviewed R1’s service plans. Based on the LPA’s review, R1’s initial service plan had been created electronically on 11/14/2024 at 5:13 PM and was electronically signed by R1’s Responsible Person/Power of Attorney (POA) on 12/02/2024 at 1:14 PM. The service plan stated that R1 required minimal assistance with meals and nutrition needs, with ‘Meal reminders or cueing to eat.’

R1’s updated second service plan was created electronically on 04/27/2025 at 4:48 PM, emailed to R1’s Responsible Person/Power of Attorney (POA) on 04/27/2025 at 4:48 PM, which stated Full assistance with Meals and nutrition – Food services support during off meal times, encourage hydration, and special diet. Notes added stated “Per resident’s POA, resident needs assistance with feeding”. The second service plan was not electronically signed by R1’s Responsible Person/Power of Attorney (POA).

On 06/04/2025, LPA reviewed R1’s Progress Notes. Based on LPA’s review, a Care Conference note had been entered electronically on 04/27/2025 at 04:56 PM. The note indicated that R1’s POA had requested assistance with feeding, and staff (S2) updated the service plan accordingly. S2 would contact ALW (Concise Care Group) regarding the increased level of care.

On 06/04/2025, LPA reviewed R1’s Assessment records. Based on the LPA’s review, the assessment had been completed electronically on 04/27/2025 at 4:46 PM. R1’s meals and nutrition needs were recorded as ‘Max-Full assistance with feeding and mealtime support’.

On 06/04/2025, LPA reviewed R1’s Activities of Daily Living (ADL) notes for April 2025. Based on LPA’s review, the records indicated that R1 had been consuming between 80% to 100% of breakfast, lunch, and dinner.

On 06/04/2025, LPA reviewed R1’s weight log. Based on LPA’s review, R1’s recorded weights were as follows: 97.5 lbs. on 01/07/2025, 96.6 lbs. on 02/02/2025, 95.5 lbs. on 03/19/2025, and 94.6 lbs. on 04/17/2025.

On 07/16/2025, LPA reviewed R1’s order for nutritional supplements. Based on LPA’s review, the order had been signed by R1’s Primary Care Physician (PCP) on 04/15/2025 and directed the administration of one Ensure per day, to be provided by the family.

Continued on LIC9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20250523161929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS	FACILITY NUMBER: 435202705
	VISIT DATE: 07/31/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/04/2025, LPA reviewed R1’s Medication Administration Record (MAR). Based on LPA’s review, Ensure had been given to R1 daily from April 15 to April 27, 2025.

Based on observations, interviews conducted, and records reviewed, the information LPA received regarding this allegation is conflicting. The department has determined that the allegation(s) may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation(s) are UNSUBSTANTIATED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Resident Care Coordinator. A copy of this report was discussed and provided to the Resident Care Coordinator, Bernadette Kang, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5