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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202705
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:31:42 PM


Document Has Been Signed on 05/12/2023 04:31 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: 21DATE:
05/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ollie VanceTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to open an initial complaint investigation. During visit, LPAs observed a violation therefore a case management - deficiencies visit was conducted. LPAs met with Administrator, Ollie Vance.

Upon arrival, LPAs was greeted at the front door by staff (S1). Upon review of the facility roster, LPAs did not observe S1 was associated to the facility. LPAs spoke with the Administrator who provided documents to include S1's live scan form and paperwork from the Department of Justice (DOJ). The review of the DOJ form shows S1 had gotten their fingerprints done on 01/09/2023. Administrator searched S1 in the Guardian system which showed S1's fingerprint application was closed therefore is not fingerprint cleared. The facility did not receive a document to confirm S1 is fingerprint cleared. S1 began work on 01/13/2023.

S1 was immediately asked to leave the facility. Administrator was informed that S1 cannot return to work until S1 is fingerprint cleared. Administrator stated understanding.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without fingerprint clearance. Please see LIC 421BG.

This report was reviewed with Administrator, Ollie Vance and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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 05/12/2023 04:31 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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2023
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by:
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Staff (S1) was immediately dismissed from work and will not return until a fingerprint clearance has been obtained. Licensee will send a written plan to ensure all staff are fingerprint cleared and associated to the facility to LPA Dolores by POC due date.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working in the facility without fingerprint clearance which poses an immediate health, safety, and personal rights risk to persons 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: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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