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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:17:57 PM

Unfounded


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
05/10/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240510105333
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: 38DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff camouflaged residents’ medication
Staff did not ensure call assistance buttons in residents’ rooms were operable
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 5/10/2024, the Department received a complaint with the above allegations. On 5/20/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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
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
05/10/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240510105333

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: 38DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
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9
Staff did not ensure to administer residents’ medication in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 5/10/2024, the Department received a complaint with the above allegations. On 5/20/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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-20240510105333
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Executive Director stated to submit a written plan on understanding regulations and schedule in-services and training to staff by POC date.
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Based on record review, interview and observation R1's 2 out of 7 meds not administered to R1 as prescribed by the MD and R2's 2 out of 6 meds were not administered to R2 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/22/2025
Section Cited
CCR
87207
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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by:
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Executive Director stated to submit a written plan on understanding regulations and schedule in-services and training to staff by POC date.
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Based on record review, interview and observation, R1-R2 electronic MARs noted medications administered but the medication bottles had either less or more than , which poses an immediate Health, Safety, or 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20240510105333
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: 05/15/2025
NARRATIVE
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Page 2 of 3.

On 5/20/2024, LPA Rai conducted a random review/audit of Assisted Living resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with Staff (S1) counted the tablets from the medication bottles. LPA Rai observed 1 out of 2 medications prescribed to resident (R1) was not given as prescribed by the doctor. R1's medication #1’s bottle contained 7 tablets where there should be 10 tablets if resident was administered the medication as prescribed by physician. LPA Rai and S1 observed 3 medication tablets were not in the medication bottle. R1's medication #5 ’s bottle contained 62 tablets where there should be 72 tablets if the resident was administered the medication as prescribed by physician. Based on review of R1's electronic MARs, S1 stated that R1's medications were administered daily from 04/01/2024 to 05/20/2024 and there was no documentation on the log about resident refusing to take medication or if resident was out of the community.

LPA Rai observed 1 out of 4 medications prescribed to resident (R2) was not given as prescribed by the doctor. R2’s medication #1’s bottle contained 25 tablets where there should be 27 tablets if the resident was administered the medication as prescribed by physician. LPA Rai and S1 observed 2 medication tablets were not in the medication bottle. R2’s medication #2’s bottle contained 20 tablets where there should be 22 tablets if the resident was administered the medication as prescribed by physician. LPA Rai and S1 observed 2 medication tablets were not in the medication bottle. R2’s medication #3’s bottle contained 10.5 tablets where there should be 2 tablets if the resident was administered the medication as prescribed by physician. LPA Rai and S1 observed additional 8.5 medication tablets in the medication bottle. R2’s medication #4’s bottle contained 15 tablets where there should be 1 tablet if the resident was administered the medication as prescribed by physician. LPA Rai and S1 observed additional 14 medication tablets were in the medication bottle. Based on review of R2's medication administration records (MARs), Staff (S1) stated that R2's medications were administered daily from 04/01/2024 to 05/20/2024 and there was no documentation on the log about resident refusing to take medication or if resident was out of the community.

LPA interviewed both staff S1 & S2 who were responsible to administer medications during the shift. S1 and S2 stated the facility policy is to administer the medication an hour before and an hour after prescribed and note on the medication administration record for any reason the resident was not administered the medication.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20240510105333
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: 05/15/2025
NARRATIVE
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Page 3 of 3.

On 5/20/2024, LPA Rai attempted to interview 8 residents, but the residents either refused to answer questions or were not able to answer the questions.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20240510105333
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: 05/15/2025
NARRATIVE
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Page 2 of 3.
Staff camouflaged residents’ medication.

It was alleged staff were putting medication in resident’s food without notifying the residents.

On 5/20/2024, LPA Rai interviewed 2 out of 2 staff (S1&S2) who are Medication Technicians who were responsible to administer medications to the residents. S1 and S2 stated residents that had a crush order would be given medications with apple, sauce, yogurt or ice cream and residents are informed when given the crushed medication with food.

On 5/20/2024, LPA Rai attempted to interview 8 residents, but the residents either refused to answer questions or were not able to answer the questions.

LPA Rai reviewed facility’s Program Plan submitted to the Department. On page 89 of Program Plan, it is regarding “Crushing Medications” which states the pharmacist will be consulted to verify which appropriate food the medication may be mixed with, and resident is clearly informed that he/she is receiving medications.

Staff did not ensure call assistance buttons in residents’ rooms were operable.

It was alleged the call lights not working in all of the rooms.

On 5/20/2024, LPA Rai randomly checked 10 call assistance buttons in the resident’s rooms and observed they were in working condition. 10 Out of 10 times the call assistance button was activated, facility staff responded and came to the room to answer the call bell alert.

On 5/20/2024, LPA Rai interviewed 3 staff. 3 Out of 3 staff stated there were no issues with the call assistance buttons in the residents’ rooms and were regularly maintained.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20240510105333
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: 05/15/2025
NARRATIVE
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Page 3 of 3.

On 5/20/2024, LPA Rai attempted to interview 8 residents, but the residents either refused to answer questions or were not able to answer the questions.

Based on review of facility logs of testing the call assistance buttons in the resident’s room, there were no issues reported in April 2024 and May 2024 logs.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7