435202705-8-13-2024-26-AS-JJIN-D9VVLF-20241009163152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:16:08 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
04/30/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240430095729

FACILITY NAME:	CRESCENT OAKS		FACILITY NUMBER:	435202705
ADMINISTRATOR:	OLLIE VANCE		FACILITY TYPE:	740
ADDRESS:	147 CRESCENT AVE		TELEPHONE:	(408) 730-4004
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	44	CENSUS: 30	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Joshua Lambengco		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident to resident altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted a complaint investigation visit and met with Joshua Lambengco, Administrator (ADM).

On 04/30/2024, the Department received a complaint with the above allegation. An initial complaint investigation visit was conducted on 05/09/2024. During visit, LPA Marrufo conducted interviews and obtained copies of resident records.

LPA Marrufo requested a police report from local law enforcement on 05/06/2024 using the police report case number provided by the complainant. Local law enforcement responded to LPA Marrufo’s request on 05/06/2024 and stated there was no police report with the provided police report case number.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 26-AS-20240430095729

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: 08/13/2024

NARRATIVE

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On 04/29/2024, the facility submitted an LIC624 Unusual Incident/Injury Report to the Department. The Incident Report stated that on 04/27/2024 at approximately 8:30 PM, care staff heard resident R2 yelling for help. Staff observed resident R1 on top of R2 while R2 was lying on the ground besides the facility main entrance. The Incident Report states R2 stated R1 pushed R2. 911 was called and Police Department and Emergency Medical Services arrived at the scene. R2 was transported to the hospital.

R1’s Physician’s Report is dated 02/17/2024 and states the date of exam as 01/30/2024. R1’s Physician’s Report states R1 has dementia. R1’s Physician’s Report states R1’s mental condition includes being confused/disoriented, inappropriate behavior, is not aggressive, and has wandering and sundowning behavior. R1’s Physician’s Report states R1 is ambulatory. The Comments Section of R1’s Physician’s Report states R1 has become unsteady on R1’s feet and has become more confused, disoriented, restless, and can no longer understand instructions. The Comments Section states R1 is ambulatory but tends to wander and may attempt to elope.

R1’s Service Plan is dated 03/18/2024 and states R1’s move-in date is 03/19/2024. R1’s Service Plan states R1 needs assistance with observation and fall management, and escorts to meals and activities. The Mobility Section of R1’s Service Plan states R1’s assistance level is “No Assist” and R1’s Mobility Needs/Details are listed as “Independent, self-care.” The Objective/Plan in the Mobility section states, “The Care Team will monitor for changes in condition and conduct a reappraisal as appropriate.” R1’s Cognitive section states R1 requires “Moderate Assist” and R1’s Needs/Details is stated as “Frequent help due to disorientation, memory loss, and difficulty completing tasks.” The Objective/Plan of the Cognitive Section states, “The Care Team supports me with orientation, redirection, and wayfinding.” The Wandering and Elopement section states R1 requires “Moderate Assist.” The Needs/Details portion states, “Occasional redirection if wandering or approaching exits.” The Objective/Plan of the section states, “The Care Team provides redirection when I am wandering or attempting to leave the building unassisted in order to help keep me safe.”

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240430095729

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: 08/13/2024

NARRATIVE

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On 05/09/2024, LPA Marrufo interviewed staff S1-S4 and R1. Staff S1-S4 each stated to have not observed the incident but were nearby assisting other residents when they heard a fall. S1-S4 stated to have then seen R1 on top of R2 on the floor by the facility main entrance. S1-S4 stated that staff provided immediate assistance to R1 and R2 and R2 was transferred to a hospital.

During interview, Administrator (ADM) Joshua Lambengco stated R1 often becomes aggressive with staff and sometimes hits staff. ADM stated R1 has hit residents in the past.

During interview, R1 was able to correctly state R1’s own name but did not correctly state R1’s location and day of the week.

During visit, ADM stated R2 moved out of the facility on 06/13/2024.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

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END REPORT

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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