435202705-8-1-2024-26-AS-KHOS-D8JN5K-20240827100941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 08/01/2024
Date Signed: 08/01/2024 11:24:43 AM

Unfounded

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
07/25/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240725150151

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: 32	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Bernadette Kang		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility did not provide supervision to resident in care, resulting to altercation between residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Resident Care Coordinator, Bernadette Kang.

On 07/25/2024, the Department received a complaint alleging that the facility did not provide supervision to resident (R1) and (R2) resulting in an altercation between residents.

On 08/01/2024, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the staff schedule, resident (R1) – (R2)’s physician’s report, service plan, progress notes, and incident reports. SEE LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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-20240725150151

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: 08/01/2024

NARRATIVE

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Based on staff interview, it was stated that staff (S1) received a call that night of the incident, 07/21/2024. The incident happened around 11:05PM inside R1 and R2’s shared bedroom. The PM staff heard noise coming from upstairs and went to check. Staff observed resident R1 sustained a minor injury to the face and R2 lifting their walker off the ground towards R1.

S1 states 3 staff responded to the incident. Staff immediately contacted 911 and police arrived to the facility a few minutes later.

After the incident, R2 was moved to a different room with the consent of R2’s responsible party.

2 residents were interviewed. Based on interview, 2 out of 2 residents remembers some parts of the incident between R1 and R2 the night of 07/21/2024. 2 out of 2 residents did not remember if staff were able to help them after the incident.

The review of the facility’s staffing schedule on 07/21/2024 shows 4 caregivers and 1 medtech was scheduled during the time of the incident.

Based on interview and record review, staff immediately responded to R1 and R2 as soon as they heard noise coming for R1 and R2’s bedroom.

The Department has investigated the above allegation. Based on interview, record review, and observation the above allegation is unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis.

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

This report was reviewed with Resident Care Coordinator, Bernadette Kang and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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