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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202705
Report Date: 09/14/2021
Date Signed: 09/15/2021 10:51:48 AM

Document Has Been Signed on 09/15/2021 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CRESCENT OAKSFACILITY NUMBER:
435202705
ADMINISTRATOR:SANDOVAL, GRACEFACILITY TYPE:
740
ADDRESS:147 CRESCENT AVETELEPHONE:
(408) 730-4004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 44CENSUS: 31DATE:
09/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Nancy RubioTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced Case Management – Incident visit today and met with Executive Director Nancy Rubio.

The purpose of the visit was, on 09/03/2021, the Department received an incident report regarding a resident (R1) left the facility unassisted on 09/02/2021. R1 was later found outside by a police officer without any injury.

LPA conducted a wellness check with R1 and observed R1 without injury. LPA interviewed the Executive Director. The Executive Director stated an inspection on the egress doors and alarms was conducted. No malfunction was observed. The Executive Director also conducted an in-service training with staff to educate and to remind the staff to make sure the doors are locked and check the surroundings when the alarms sound.

Record review of R1’s physician’s report showed R1 has mild cognitive impairment who is unable to leave facility unassisted. Deficiency was cited during visit today. See LIC809-D.

This report was reviewed with the Executive Director.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2021 10:51 AM - It Cannot Be Edited


Created By: Yatfai Ng On 09/14/2021 at 09:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CRESCENT OAKS
FACILITY NUMBER: 435202705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2021
Section Cited
HSC
87464(f)(1)

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87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision… (c) … means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental
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Executive Director already submitted a training record and an action plan before the POC due date.
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health, safety, or welfare would be endangered... This requirement was not met as evidenced by:
Based on record review, R1's physician's report shows R1 is unable to leave facility unassisted. R1 was found outside of the facility unassisted.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Yatfai Ng
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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