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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202705
Report Date: 01/10/2025
Date Signed: 01/10/2025 12:10:36 PM

Substantiated


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
01/07/2025 and conducted by Evaluator Kiran Jain
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20250107125539
FACILITY NAME:CRESCENT OAKSFACILITY NUMBER:
435202705
ADMINISTRATOR:JOSHUA LAMBENGCOFACILITY TYPE:
740
ADDRESS:147 CRESCENT AVETELEPHONE:
(408) 730-4004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:44CENSUS: 35DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Geraldine Sabado, Activities Director TIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff do not ensure the elevator is working properly
INVESTIGATION FINDINGS:
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On January 10, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Complaint Investigation visit. Upon arrival, the LPA was greeted by the Activities Director (AD), Geraldine Sabado. The LPA disclosed the purpose of the inspection. The AD informed the LPA that there were (35) residents in care.

Regarding the allegation “Staff do not ensure the elevator is working properly”, the Reporting Party (RP) stated “The elevator has not been working for weeks. The management does not seem to be in a hurry to fix it.”.

LPA interviewed (1) Resident (R1). R1 was observed to be sitting in the lobby area along with other (6) residents of the 2nd floor. R1 stated that elevator had been broken for about (2) weeks, right after Christmas and most of the residents had to stay upstairs and had not been able to leave the 2nd floor.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 4
Control Number 26-AS-20250107125539
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: 01/10/2025
NARRATIVE
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R1 stated R1 had been taking stairs to go down. R1 stated that the caregivers bring food upstairs from the kitchen in trays and one of the caregivers tripped and fell while carrying the food tray. R1 stated that this caregiver who tripped and fell on the stairs was not here today and don’t know their name. R1 stated that their roommate was stuck in their room. R1 further stated that they haven’t heard when the parts for the elevator was going to be here to fix the elevator.

LPA interviewed (4) Staff members (ED, AD, S1, and S2). LPA talked to the Executive Director (ED) over the phone. ED stated the elevator stopped working about a week ago, staff was supervising residents upstairs. The families were informed about the broken elevator. ED stated they had been in touch with the TK company for the elevator repair, motor needed to be replaced and it was a special order. ED stated they received an email from TK company that part would tentatively come today, and vendor would come to fix it as soon as the part arrived. LPA asked ED to email LPA information 1) Exact date when the elevator stopped working 2) Date when the families were notified 3) Email communication with TK company regarding the repair. 4) Copy of regular elevator maintenance and elevator inspection records.

AD stated that the elevator had not been working for past (1) week, parts are old and had been ordered, and vendor was waiting for the part. AD stated that residents on 2nd floor stay upstairs, they do one on one activities with the residents upstairs and food is served upstairs. AD stated if resident had a doctor appointment, then (2) staff member would help to bring the resident downstairs. AD stated that one the caregivers tripped on the last step of the stairs while carrying food tray but didn’t fell. AD stated the caregiver missed one step, was checked up by the doctor, and was not present at the facility today. AD stated that as far as they know elevator stopped working a day before New Years.

S1 stated they were on vacation when elevator broke down (2) weeks ago. Parts had been ordered and part was going to come today, and elevator would be fixed after that. S1 stated they helped to bring (2) residents down since residents had to go to the hospital. (3) male staff members helped to bring the residents down.

S2 stated the elevator stopped working for more than (2) weeks ago and they had been told by the boss that parts were hard to find. Elevator is old. S2 stated residents who cannot walk and were on wheelchairs stayed upstairs, may be only 4-5 residents can walk on their own. S2 stated staff carried food upstairs and one of the caregivers fell on the stairs while carrying food tray, another staff member helped the caregiver to get up. S2 stated they all took turns, but it was hard to go up and down the stairs.

Continued on 9099-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250107125539
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: 01/10/2025
NARRATIVE
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LPA observed broken elevator in an non-operational state and took stairs with AD to go to the 2nd floor and then back to the 1st floor. There was no “Out of Service” sign posted outside the elevator on the 1st floor, however, LPA observed “Please do not use elevator! Out of Service” sign posted outside the elevator on the 2nd floor. LPA observed (7) residents sitting in the lobby area watching TV.

LPA reviewed facilities resident roster and there were (20) residents living on the 2nd floor and (15) residents living on the 1st floor.

Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

A deficiency in accordance with the California Code of Regulations, (Title 22, Division 6 & Chapter 8), is being cited on the attached LIC 9099D.

An exit interview was conducted, and the Plan of Correction was reviewed and developed with the Activities Director. A copy of this report and appeal rights were discussed and left with the Activities Director, Geraldine Sabado, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20250107125539
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: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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The Activities Director stated that they would fix the elevator as soon as the part is delivered. The Executive Director will submit the evidence of a working elevator, including photographs and a copy of the elevator repair invoice to CCLD by 01/17/2025.
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Based on observation and interview, the licensee did not ensure (1) elevator is usable and is in good repair for (20) of (20) residents on the second floor (R1-R20) which poses a potential 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: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4