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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202705
Report Date: 12/30/2022
Date Signed: 12/30/2022 02:37:55 PM


Document Has Been Signed on 12/30/2022 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OAKSFACILITY NUMBER:
435202705
ADMINISTRATOR:OLLIE VANCEFACILITY TYPE:
740
ADDRESS:147 CRESCENT AVETELEPHONE:
(408) 730-4004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:44CENSUS: 28DATE:
12/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Ollie VanceTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management inspection in response to an incident report submitted by the facility on 12/29/2022. LPA met with facility administrator Ollie Vance (Admin).

The report detailed an incident in which a facility resident (R1) tried to leave the facility multiple times on 12/23/2022. 2 staff members (S1-2) responded by taking off R1's shirt, and locking him outside. This was ostensibly done to teach R1 a lesson, and to disincentive him from wanting to leave the facility. A witness was able to take a video of the situation, which revealed that another staff member (S3) had participated via Facetime. S1-3 are seen laughing and telling R1 to ring the doorbell if he wants to be let back inside. An additional staff member (S4) is heard asking who is outside shortly before the video ends. R1 was visibly distressed in the video footage.

LPA asked facility Admin whether the staff were still working at the facility. Admin stated that management was made aware of the incident on 12/28/2022, conducted a full investigation on the same day, and terminated the 4 staff members documented in the video on 12/29/2022. Admin stated that she was not aware of any additional incidences of abuse that have occurred onsite before or since the incident.

LPA interviewed R1. R1 answered LPA's questions primarily in single word responses. When asked whether he liked living at the facility. R1 stated that he did. When LPA asked if R1 liked the staff, R1 stated that he did. When asked if staff have ever treated him rudely or unkindly, R1 stated that they probably did, but could not recall a single incident, but stated that there have been misunderstandings and that he is misunderstood. R1 was unable to elaborate. LPA thanked R1 for his time and concluded the interview.

Deficiency cited, See 809-D This report was reviewed with facility Administrator Ollie Vance and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/30/2022 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2022
Section Cited

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87468.1 - Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have... the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee has already terminated the employees responsible for the violation and has already conducted an inservice training on elder abuse and personal rights for all staff at the facility. POC CLEARED
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Based on interviews and records review, the licensee did not comply with the section cited based on 4 staff members treating a resident of the facility without dignity. This posed an immediately health and safety risk to residents in care.
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
LIC809 (FAS) - (06/04)
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