435202705-8-13-2024-26-AS-KHOS-DABGWX-20241023054304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:12:10 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
06/03/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240603132838

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: 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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Staff did not provide adequate food service
Staff don't respond to residents' call assistance button promptly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced compliant investigation visit and met with Joshua Lambengco, Administrator (ADM). On 06/03/2024, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint investigation visit on 06/05/2024.

The Department cross-reported the complaint to local law enforcement. On 06/04/2024, the Department conducted a telephone interview with a police officer from local law enforcement who visited and toured the facility on 06/04/2024. The police officer stated to have toured the kitchen and observed the refrigerator and observed food of good quality. The police officer stated to have viewed the facility menus and records and was able to see residents being served special diets.

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-20240603132838

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 06/05/2024, LPA Marrufo toured the facility food storage areas, kitchen, and 4:30 PM meal service. LPA did not observe any spoiled food. LPA observed residents being served meat balls with white rice and spinach with chicken noodle soup. LPA did not observe any of the served food to be spoiled. LPA Marrufo observed staff serving meals and drinks to residents.

On 06/05/2024, LPA Marrufo pulled the emergency pull cords in two resident bedroom bathrooms. Facility staff responded to the first emergency pull cord in 1 minute and 38 seconds. The staff responded to the second emergency pull cord in 37 seconds.

On 06/05/2024, LPA Marrufo interviewed staff S1-S5 and resident R1-R2. Staff S1-S5 stated to have not observed staff provide inadequate food service. S1-S5 stated to have not observed staff not respond to a residence call assistance button promptly. Residents R1 stated to have not observed staff provide inadequate food service and to never observed staff not respond to resident’s call assistance buttons promptly. R2 stated that sometimes the food is too hard. R2 stated R2’s emergency pull cord does not work and that R2 does not use the emergency pull cord.

On 08/13/2024, LPA Marrufo conducted telephone interviews with resident Family Members (FM) FM1-FM5. FM1, FM2, and FM3 stated to have not observed staff not provide adequate food services or staff not responding to resident’s call assistance buttons promptly. FM4 and FM5 stated that resident R3 has complained to them about the food at the facility. FM4 and FM5 stated to have not observed staff not respond to residents’ emergency pull cords promptly.

During visit on 08/13/2024, LPA Marrufo triggered 3 out of 3 emergency pull cords in resident R2’s bedroom. All 3 emergency pull cords functioned properly when pulled. LPA Marrufo waited for 12 minutes and 30 seconds. A staff appeared near the door but entered into a neighboring resident’s room. LPA Marrufo stepped out of R2’s bedroom and asked the staff if the staff is responding to the emergency pull cord. The staff stated to be covering the second floor but did not remember to bring a radio. LPA Marrufo asked the staff to retrieve the radio in order to be able to be made aware of the emergency cord signals.

Page 2 of 3.

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: 3 of 3

Control Number 26-AS-20240603132838

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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LPA tested an emergency pull cord in a second room and the staff responded in 10 seconds.

ADM states that there is no written policy on the time staff have to respond to emergency pull cord signals. ADM provided LPA with a copy of the Employee Expectations Guidebook that states, “Respond in a timely ma[nn]er to call lights.

ADM states there is no log of the emergency signal response times.

Advisory Notes were issued. See LIC9102 pages for more information.

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

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Joshua Lambengco and a copy of this report was provided.

Page 3 of 3.

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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