435202705-10-30-2024-26-AS-KHOS-DARRVE-20241106122125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:31:50 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
05/09/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230509114956

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: 34	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Joshua Lambengco		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not ensuring a safe environment for residents in care.
Staff are mismanaging resident's medications.
Staff are not ensuring that residents are administered their medications as prescribed.
Staff are not regularly informing resident's representatives of information related to the care or services for residents in care.
Staff are not ensuring that residents have a reasonable ability to receive confidential calls.
Staff are not reporting incidents involving residents as required.
Staff yell at residents in care.

INVESTIGATION FINDINGS:

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On 10/30/24, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Joshua Lambengco and explained the purpose of the visit.

Regarding the allegations that staff are not ensuring a safe environment for residents in care, staff are not regularly informing resident's representatives of information related to the care or services for residents in care and staff are not reporting incidents involving residents as required, reporting party (RP) stated that ADM keeps information about the care and supervision of residents from loved ones, and misleads them about the resident's care and experiences. ADM doesn't want people to know what is really going on at this facility. Some of the residents that are allowed to live in this facility are very combative and are harassing other residents. For example, about 2 months ago a resident hit another resident which caused a bruise on their shoulder. This incident (and other incidents) was never reported to anyone.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 7

Control Number 26-AS-20230509114956

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: 10/30/2024

NARRATIVE

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According to the interviews conducted, S2 mentioned that he/she doesn’t know if there was previous issues. Before S2 came in, there were some issues with medications with signing off medications. S2 implemented it when he/she started. S2 told them they have to log it in especially Narcotic. PM shift always complained to her before that medications were not being ordered. Never experienced of medications being misplaced or lost. Residents take their medications. They always receive their medications and they get their meds every day. S4 mentioned that he/she has to talk to S5 about medications not being ordered on a timely basis. Their procedures are outside pharmacy contact them before 14 days. Contracted pharmacy should be contacted before 7 days. As far as what S4 knows, there’s no missed medications. S4 hasn’t heard of medications being lost or misplaced.

Based on records reviews, all medications are logged appropriately both in the Centrally Stored Medication and Destruction Records (CSMDR) and Medication Administration Records (MAR) for five randomly picked resident records.

Regarding the allegation of staff are not ensuring that residents have a reasonable ability to receive confidential calls, RP state that when family members have a scheduled time to call a resident in care and try to call, staff do not answer the phone because there are not enough staff at this facility, so residents are not able to speak to their loved ones.

During the interview, S1 mentioned that the residents are able to receive and make phone calls. They just ask the MedTech if they want to use the phone. MedTech’s only pick up the phone. The landline is in the office. With MedTech phone, they have cell phone, and they do video calls. No never had a moment a resident is not able to talk to loved one because they’re short of staffed. Some of the residents take a long time to talk on the phone. S2 stated that if residents don't have a phone, they have to get a phone for them. S2 gives the phone to their ears. They’ll just listen. Yes, it happens when they're not able to pick up the phone right away. S2 returns the call and mostly it’s the family. S2 calls them back right away as soon he/she receives the message. S3 shared that there are no issues with the telephone communications. Residents are able to use the telephone.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20230509114956

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: 10/30/2024

NARRATIVE

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LPA Dolores was able to interview four staff members. S1 mentioned that if an incident were to occur like a fall, they need to recognize the fall, call 911 or call the Administrator (ADM) or Resident Care Coordinator (RCC). If they have blood, they call 911. They also need to call the family. S2 shared that incidents like unwitnessed fall they would call 911 right away. If they’re hospice they call hospice first, and if hospice decide to call 911, they call. They also call ADM or RCC and call family. The MedTech’s also does the incident report and take vital signs. S4 also shared that S5 will communicate with family or MedTech and ADM will step in if need to. They'll communicate if there’s any fall, change of condition, missed medication, anything wrong with the residents. Sometimes things do slip through the cracks and if it does, they’ll try to address it and try to apologize if it’s not reported right away. They usually do it on August health or communication through family. S1, S2 and S3 all mentioned that there are no combative residents in the facility during the time of the interview.
LPA Donato was able to interview four out of seven family members. All mentioned that they are being provided with constant updates. R2 mentioned that they don’t really speak directly with ADM1 but it's the MedTech’s who call and give updates about any changes.

LPA Donato & Dolores are not able to confirm the incident of a resident hitting another resident since there is no contact information for the reporting party.

Based on records review, there was no report of an incident regarding a resident hitting another resident that was submitted to Licensing. However, there were constant reports of unusual incidents that happen in the facility since January 2023. Records also show reappraisals of four residents (R1, R2, R3,& R4) are updated and signed by responsible parties.

Regarding the allegation of staff are mismanaging resident's medications and staff are not ensuring that residents are administered their medications as prescribed, RP stated that medications are not being ordered on a timely basis, so residents are not getting their medications, and, when medication orders come in the medications are often misplaced or lost, so residents are not getting their medications. ADM1 will tell family members that the residents got their medications even when they didn't. The medical technician is saying that the residents "never get their meds."

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20230509114956

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: 10/30/2024

NARRATIVE

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Regarding the allegation of staff yelling at residents in care, RP stated that many of the caregivers have not been trained on how to work with residents who have dementia, and it is evident in the way they treat the residents (yell at them, don't redirect them, etc.)

According to staff interviews, S1 said that normally residents are treated well. From S1’s observation they’re treating the residents well. Never witnessed a staff yell at another resident. S2 stated that everybody is nice to the residents. Never observed anyone yell at a resident. S3 shared that none of the staff are yelling at the residents. S4 also mentioned that he/she feels the residents are treated great here. Haven't witnessed anyone yelling at the residents.

Based on interviews & records review, the department has determined that although the allegations 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.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7

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
05/09/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230509114956

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: 34	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Joshua Lambengco		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not adequately trained.
Staff are not ensuring that residents are provided with activities while in care.

INVESTIGATION FINDINGS:

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On 10/30/24, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Joshua Lambengco and explained the purpose of the visit.

Regarding the allegation of staff are not adequately trained, RP stated that Many of the caregivers have not been trained on how to work with residents who have dementia.

According to interviews, S1 mentioned that training is provided almost every month. They had skin training. They've done training for transferring and dementia training. Believes it was done in October 2022. Hospice – Vitas or home health does the training. S2 stated that he/she received medication training every year, did medication training a month ago. S3 shared that caregivers does training. They have in-service training and have regional to check in and check on them. Monthly they have in-service training. S4 said that training is done monthly.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20230509114956

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: 10/30/2024

NARRATIVE

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Based on records review, there were several in service training's conducted between February 2023 to April 2023. Topics that were discussed were Hospice, Dementia, Workplace Bullying, Care for Residents, Transfers & Skin Care. Training was provided by different instructors/trainers. A random selection of six staff members training records was requested and all have logged training's, for when they were hired, with the following topics: Assisting a resident with dressing and undressing, hands-on shower, transferring in/out of bed and in/out of wheelchair, helping a resident with personal grooming, including denture care, assisting a resident who has had an incontinent episode, assisting residents with dementia diagnosis in ADL care.

Regarding the allegation of staff are not ensuring that residents are provided with activities while in care, RP stated that residents are not being provided with activities (again, because the facility does not have enough staff) so residents just sit in their rooms with nothing to do.

During the interviews, S1 mentioned that they are providing activities. Once a month they have special occasion activities. Sometimes on weekends because they don’t have activity person, they don't have much activities. They try to help with activities on weekends, but they have many visitors. They didn’t have enough staff to do activities and care for the visitors. Sometimes if they don’t show up to the activities, they’ll do videos for exercise. They’ll still try but cannot force the residents. S2 shared that the activities they have are bingo, drawing, coloring, dancing, music, watch games on the TV. Every day they have activities and even night before dinner. They would play cards. No days when they don’t have activities because the activities person prepares things for them. The activities are in the closet. Some residents ask if they have activities today. Even on the weekends there is activities. S3 stated that They have an activities calendar. Monthly they always have the activities and it’s subject to change. They are memory care and cannot expect all the residents to do the activities, but it’s subject to change. There are days they’re not into the activity and they have plan b and plan c aside from the activity calendar. The staff has easy accessibility to the activities for the days when activity person is not here especially on weekends.

LPA Donato also observed residents were having some activities in the dining area after lunch was served.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20230509114956

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: 10/30/2024

NARRATIVE

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Based on records review, the facility provided LPA a copy of a comprehensive calendar of activities from January 2023 to April 2023. Activities include, Sunday worship, crafts, bingo, balloon swat, movies, travel videos, chair Zumba, etc. On the March - May 2023 schedule provided, there are 5 caregiver staff scheduled plus a MedTech.

Based on interviews, observations & records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7