Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
77% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 34
Capacity: 44
Deficiencies: 0
Date: Mar 5, 2026
Visit Reason
The inspection was an unannounced case management incident visit conducted in response to a complaint alleging that staff yelled at residents when they requested food during non-meal times.
Complaint Details
The complaint alleged staff yelling at residents when they ask for food outside meal times. The investigation found no substantiation of yelling; staff explained the loud voices were to aid residents with hearing impairments.
Findings
Interviews with five staff members revealed that staff do not yell at residents but speak loudly to accommodate residents with hearing difficulties. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Riley Tucker | Executive Director | Met with Licensing Program Analyst during the visit. |
| Nick Catalano | Met with Licensing Program Analyst during the visit. | |
| Joshua Lambengco | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 44
Deficiencies: 1
Date: Feb 18, 2026
Visit Reason
The inspection was an unannounced case management - incident visit conducted in response to a reported incident where a staff person pushed a resident on 2026-01-29. The visit aimed to investigate and assess the incident.
Complaint Details
The visit was complaint-related, triggered by an SOC341 report received on 2026-02-02 regarding a staff person pushing a resident on 2026-01-29. The incident was confirmed and substantiated.
Findings
The investigation confirmed the incident occurred based on eyewitness accounts and internal investigation. The staff member involved was suspended the same day. A deficiency was cited related to resident rights due to confirmed abuse involving a med-tech pulling a resident's hair, posing an immediate health and safety risk.
Deficiencies (1)
Violation of CCR 87468.1(a)(2) Personal Rights of Residents - med-tech observed pulling the hair of a resident, confirmed by camera footage and witness, posing immediate health and safety risk.
Report Facts
Capacity: 44
Census: 34
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nick Catalano | Administrator | Met with Licensing Program Analyst during inspection and involved in incident response |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection and investigation |
| Cara Smith | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 0
Date: Dec 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2025-11-21 regarding staff failure to prevent a client from pushing another client.
Complaint Details
The complaint alleged that staff failed to prevent a client from pushing another client, resulting in a closed head injury. The allegation was unsubstantiated after review of reports, interviews, and documentation.
Findings
The investigation found that staff were unable to prevent the client from harming another resident, but staff reacted appropriately to intervene. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.
Report Facts
Caregivers on work schedule: 4
Med tech and housekeeper: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Evaluator | Conducted the complaint investigation |
| Joshua Lambengco | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 44
Deficiencies: 3
Date: Oct 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation to observe deficiencies related to the California Code of Regulations, Title 22, and to review training records for staff VSC.
Complaint Details
The visit was complaint-related. During the investigation, deficiencies were observed and citations issued. The complaint involved incidents on 8/23/25 and 10/7/25 where client #2 behaved aggressively towards staff and other clients, and required incident reports were not submitted.
Findings
Deficiencies were found including failure to submit required incident reports after aggressive client behavior, lack of dementia training records for staff VSC, and absence of a certified RCFE administrator. Citations were issued and plans of correction were required.
Deficiencies (3)
Failure to submit written incident reports to the licensing agency within 7 days of incidents threatening resident welfare, safety, or health.
Failure to ensure staff VSC received required dementia training including initial and annual hours.
No RCFE certified administrator employed at the facility, lacking qualified management coverage.
Report Facts
Capacity: 44
Census: 38
Plan of Correction Due Date: Nov 12, 2025
Plan of Correction Due Date: Oct 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Cowan April | Licensing Program Manager | Named in report as licensing program manager |
| Joshua Lambengco | Administrator/Director | Facility administrator noted as lacking RCFE certification |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 44
Deficiencies: 1
Date: Oct 29, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2025-10-17 alleging that facility staff did not prevent a resident from hitting another resident.
Complaint Details
The complaint was unsubstantiated. Although the allegation may have occurred or is valid, there was not enough evidence to prove the alleged violation did or did not occur.
Findings
The allegation was determined to be unsubstantiated due to insufficient evidence. Despite multiple documented incidents involving the instigator resident's aggressive behavior, staff intervened appropriately but lacked a dedicated caregiver for 24/7 supervision. Deficiencies of the CA Code of Regulations, Title 22 were observed during the investigation.
Deficiencies (1)
Deficiencies of the CA Code of Regulations, Title 22 were observed during the investigation.
Report Facts
Capacity: 44
Census: 38
Documented incidents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator | Conducted the complaint investigation |
| Joshua Lambengco | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 44
Deficiencies: 2
Date: Oct 22, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with California Code of Regulations, Title 22, following allegations that triggered the visit.
Complaint Details
During complaint investigation visit, deficiencies of the California Code of Regulations, Title 22 were observed, and civil penalty was assessed.
Findings
Deficiencies were observed related to personnel requirements, including failure to obtain criminal record clearance for an administrator employed over 30 days, and failure to timely notify the Department of a new administrator. Civil penalties were assessed.
Deficiencies (2)
Failure to obtain criminal record clearance for administrator employed over 30 days, posing immediate health, safety, or personal rights risk to clients.
Failure to notify the Department in writing within 30 days of hiring a new administrator, posing potential health, safety, or personal rights risk to clients.
Report Facts
Capacity: 44
Census: 38
Plan of Correction Due Date: Oct 24, 2025
Plan of Correction Due Date: Oct 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zari | Administrator | Named in deficiency for lack of criminal record clearance and late notification of employment |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 44
Deficiencies: 1
Date: Aug 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including untimely incontinence care, residents not kept clean and dry, missed meals, resident injury, communication issues between staff and residents, lack of dental hygiene assistance, and failure to provide shower services as per admission agreement.
Complaint Details
The complaint investigation was substantiated regarding staff not ensuring timely incontinence care and residents being kept clean and dry. Other allegations such as missed meals, resident injury, communication issues, dental hygiene assistance, and shower services were investigated with mixed findings. The complaint control number is 26-AS-20240619104312.
Findings
The investigation substantiated the allegations related to incontinence care and residents not being kept clean and dry, citing use of double diapers due to resident behavior. Other allegations such as missed meals, resident injury, communication barriers, dental hygiene assistance, and shower services were found unsubstantiated or partially substantiated with explanations provided by staff and records. Deficiencies were cited under California Code of Regulations, Title 22, Section 87468.1(a)(1) related to personal rights of residents.
Deficiencies (1)
Failure to accord dignity in personal relationships with staff and residents, evidenced by incontinence care issues including use of double diapers and resident behavior.
Report Facts
Capacity: 44
Census: 39
Deficiencies cited: 1
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Joshua Lambengco | Administrator | Facility administrator met with evaluator during investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 44
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-05-05 that staff did not dispense medication as prescribed and did not assist a resident with eating.
Complaint Details
The complaint included allegations that staff did not dispense medication to residents R1 and R2 as prescribed and did not assist resident R2 with eating. The investigation included interviews with staff, residents, responsible persons, and review of medical and service records. The complaint was found to be unsubstantiated.
Findings
The investigation found conflicting information regarding the allegations. Staff and residents reported that medications were administered as prescribed and assistance with feeding was provided. The facility had updated service plans and documentation supporting care. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Report Facts
Capacity: 44
Census: 39
Weight: 97.5
Weight: 96.6
Weight: 95.5
Weight: 94.6
Medication administration time: 7.56
Medication administration frequency: 2
Medication application time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bernadette Kang | Resident Care Coordinator | Facility representative who received and discussed the report |
| Joshua Lambengco | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 44
Deficiencies: 0
Date: Jul 31, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff did not assist a resident (R1) with feeding, resulting in weight loss.
Complaint Details
The complaint alleged that facility staff did not assist resident R1 with feeding, resulting in weight loss. The allegation was unsubstantiated after investigation, with evidence showing staff provided feeding assistance and R1's condition was related to ALS progression rather than neglect.
Findings
The investigation found conflicting information regarding the feeding assistance provided to R1. Staff reported assisting R1 during meals, and the resident's primary care physician confirmed that R1 received assistance consistent with their condition. The allegation was determined to be unsubstantiated due to insufficient evidence to prove violations occurred.
Report Facts
Capacity: 44
Census: 39
Weight measurements: 97.5
Weight measurements: 96.6
Weight measurements: 95.5
Weight measurements: 94.6
Ensure administration period: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bernadette Kang | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation and received the report |
| Joshua Lambengco | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 44
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-10 regarding medication administration and call assistance button operability at Crescent Oaks facility.
Complaint Details
The complaint investigation was substantiated for medication administration issues but unfounded for allegations of medication camouflaging and call assistance button failures.
Findings
The investigation substantiated that staff did not administer residents' medications in a timely and accurate manner, with discrepancies found in medication counts posing immediate health and safety risks. However, allegations regarding staff camouflaging medication and non-operable call assistance buttons were found to be unfounded.
Deficiencies (2)
Facility personnel were not competent to provide necessary services as evidenced by failure to administer medications as prescribed, posing immediate health and safety risks.
False claims made regarding medication administration records, with discrepancies between electronic MARs and actual medication bottle counts posing immediate health and safety risks.
Report Facts
Census: 38
Total Capacity: 44
Deficiencies cited: 2
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Simranjit Rai | Licensing Program Analyst | Conducted the complaint investigation |
| Ollie Vance | Administrator | Facility administrator involved in the investigation |
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during inspection |
| Romeo Manzano | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 38
Capacity: 44
Deficiencies: 0
Date: May 9, 2025
Visit Reason
The inspection was an unannounced Required 1-Year Annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with all applicable regulations. No deficiencies were cited during the visit. Safety equipment, resident rooms, common areas, medication storage, and staff records were all inspected and found satisfactory.
Report Facts
Number of resident rooms inspected: 8
Number of client files reviewed: 5
Number of staff personnel records reviewed: 5
Days supply of fresh perishable food: 2
Days supply of nonperishable staples: 7
Date of last fire extinguisher service: Feb 7, 2024
Date of last emergency drill: Feb 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Geraldine Sabado | Activities Director | Met with Licensing Program Analyst during inspection and tested smoke and carbon monoxide detectors. |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Plan of Correction
Census: 39
Capacity: 44
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
The visit was an unannounced Proof of Correction (POC) inspection to verify the correction of a previously cited deficiency regarding a broken elevator.
Findings
The elevator was observed to be operational and working for residents and staff. The previously cited deficiency for maintenance and operation was cleared. However, the elevator permit posted was expired, and the facility is in the process of obtaining a new permit.
Report Facts
Capacity: 44
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geraldine Sabado | Activities Director | Met with Licensing Program Analyst during the inspection and accompanied the inspection |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit |
| Joshua Lambengco | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 44
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not ensure the elevator is working properly.
Complaint Details
The complaint alleged that staff do not ensure the elevator is working properly. The allegation was substantiated based on interviews, observations, and review of facility records.
Findings
The elevator had been broken for about two weeks, restricting residents on the second floor from leaving. Staff reported difficulties in managing residents and food service due to the elevator outage. The elevator was observed to be non-operational with inadequate signage on the first floor. The allegation was substantiated, and a deficiency was cited for failure to maintain the elevator in good repair.
Deficiencies (1)
The facility did not ensure the elevator was usable and in good repair for 20 residents on the second floor, posing a potential health, safety, or personal rights risk.
Report Facts
Residents on second floor: 20
Residents on first floor: 15
Total residents: 35
Facility capacity: 44
Plan of Correction due date: Jan 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geraldine Sabado | Activities Director | Met with Licensing Program Analyst and involved in plan of correction |
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joshua Lambengco | Administrator | Facility administrator named in the report |
| April Cowan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 44
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding insufficient administrator presence, staff not following infection control and hand washing practices, failure to provide hand washing soap to residents, and staff not responding to residents' requests for assistance.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient administrator hours, staff not following infection control and hand washing practices, failure to provide hand washing soap, and staff not responding to resident requests. Interviews and observations did not confirm these allegations.
Findings
Based on observations, interviews with staff, residents, and responsible parties, and records review, the department found no preponderance of evidence to substantiate the allegations. Staff were observed following infection control practices, providing hand washing soap, and responding to resident needs within expected timeframes. No deficiencies were cited.
Report Facts
Facility capacity: 44
Census: 34
Administrator hours: 4
Call light response time: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation visit |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bernadette Kang | Resident Care Coordinator | Met with investigators and involved in findings discussion |
| Joshua Lambengco | Administrator | Facility administrator mentioned in allegations and interviews |
| April Cowan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 44
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2023-05-09 regarding staff practices and resident care at Crescent Oaks facility.
Complaint Details
The complaint included allegations of unsafe environment, medication mismanagement, failure to administer medications as prescribed, lack of communication with residents' representatives, failure to ensure confidential calls, failure to report incidents, and staff yelling at residents. The investigation concluded these allegations were unsubstantiated or unfounded due to insufficient evidence.
Findings
The investigation found that although some allegations may have happened or be valid, there was not a preponderance of evidence to prove violations occurred. Medication management, resident safety, communication, and staff behavior allegations were unsubstantiated or unfounded based on interviews, records review, and observations.
Report Facts
Capacity: 44
Census: 34
Number of allegations: 9
Number of staff training records reviewed: 6
Number of family members interviewed: 7
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Evaluator | Conducted the complaint investigation visit |
| Joshua Lambengco | Administrator | Facility administrator met during investigation |
| Ollie Vance | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 44
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 06/03/2024 regarding inadequate food service and delayed response to residents' call assistance buttons.
Complaint Details
The complaint was unsubstantiated. Allegations included inadequate food service and staff not responding promptly to call assistance buttons. Interviews with staff, residents, family members, and observations did not support these claims sufficiently to prove violations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews indicated food was of good quality and staff generally responded promptly to emergency pull cords, though one incident showed delayed response due to lack of radio communication. Advisory notes were issued, but no deficiencies were cited.
Report Facts
Emergency pull cord response time: 98
Emergency pull cord response time: 37
Emergency pull cord response time: 750
Emergency pull cord response time: 10
Census: 30
Total Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during complaint investigation and discussed findings. |
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 44
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-04-30 alleging lack of supervision resulting in a resident-to-resident altercation.
Complaint Details
The complaint alleged lack of supervision resulting in a resident-to-resident altercation. The investigation included interviews with staff and review of records. The allegation was determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation found that although the incident may have occurred, there was not a preponderance of evidence to substantiate the allegation. No deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Facility capacity: 44
Census: 30
Complaint received date: Apr 30, 2024
Initial complaint investigation date: May 9, 2024
Resident move-out date: Jun 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted complaint investigation visit |
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during investigation and provided statements |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 44
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted due to an allegation that the facility did not provide supervision to residents, resulting in an altercation between residents.
Complaint Details
The complaint alleged lack of supervision leading to an altercation between residents R1 and R2 on 07/21/2024. The investigation included interviews, document review, and observation, concluding the allegation was false and without reasonable basis.
Findings
Based on staff interviews, record review, and observation, the allegation was found to be unfounded. Staff responded immediately to the incident, and no deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Staff scheduled: 5
Residents interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Bernadette Kang | Resident Care Coordinator | Met with Licensing Program Analyst during investigation and reviewed report |
| Joshua Lambengco | Administrator | Facility administrator named in report header |
| Sarah Yip | Supervisor | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 42
Capacity: 44
Deficiencies: 0
Date: May 31, 2024
Visit Reason
An unannounced Case Management - Annual Continuation visit was conducted to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analyst reviewed staff records, inspected food supplies, bathrooms, resident bedrooms, and facility exits, finding all areas compliant with no deficiencies cited. A request was made for submission of smoke detector and emergency drill logs by 06/05/2024.
Report Facts
Staff records reviewed: 5
Perishable food supply days: 2
Non-perishable food supply days: 7
Hallway bathrooms observed: 1
Resident bedrooms observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during the inspection and reviewed the report |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management - Annual Continuation visit |
Inspection Report
Annual Inspection
Census: 28
Capacity: 44
Deficiencies: 0
Date: May 9, 2024
Visit Reason
An unannounced Required 1 Year visit was conducted as part of the annual inspection process.
Findings
The Licensing Program Analyst reviewed resident records and Centrally Stored Medication Logs for 5 residents, all found to be complete. No deficiencies were cited at this time per California Code of Regulations Title 22. The inspection will be continued at a later date due to time constraints.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report. |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Required 1 Year visit and reviewed resident records. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Feb 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of insufficient staffing to meet resident needs received on 08/24/2021.
Complaint Details
The complaint alleged insufficient staffing to meet resident needs. The investigation included interviews with staff and review of facility schedules, which showed adequate staffing levels. The allegation was found to be unsubstantiated.
Findings
Based on interviews, observations, and record reviews, the department determined there was not a preponderance of evidence to prove the alleged violation occurred, and therefore the allegation was unsubstantiated.
Report Facts
Capacity: 44
Census: 28
Scheduled caregivers: 4
Scheduled caregivers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Ollie Vance | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 0
Date: Feb 16, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation of insufficient staffing to meet resident needs at Crescent Oaks facility.
Complaint Details
The complaint alleged insufficient staffing to meet resident needs, including temporary agency staff sometimes being unavailable. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that while some staff reported occasional insufficient staffing and agency staff not showing up or arriving late, other staff disagreed. Based on interviews and record reviews, there was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.
Report Facts
Capacity: 44
Census: 28
Staff scheduled: 5
Staff scheduled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ollie Vance | Administrator | Facility administrator met during the investigation |
Inspection Report
Census: 28
Capacity: 44
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
The visit was an unannounced Case Management visit to address two separate incidents of medication errors that occurred on 2023-10-02 and were self-reported by the facility via Unusual Incident Reports.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued regarding the medication errors and a Plan of Action was requested to address ongoing staff training and mitigation to prevent future errors.
Report Facts
In-Service Training Records: 4
Med Room Checklists: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Ollie Vance | Administrator | Facility Administrator met during the visit and requested to submit a Plan of Action |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 44
Deficiencies: 1
Date: May 12, 2023
Visit Reason
Licensing Program Analysts arrived unannounced to open an initial complaint investigation. During the visit, a violation was observed, leading to a case management - deficiencies visit.
Complaint Details
Initial complaint investigation was opened due to concerns about staff fingerprint clearance. The complaint was substantiated as a violation was found.
Findings
Staff member (S1) was found working at the facility without fingerprint clearance as required by California Code of Regulations, Title 22. S1 was immediately dismissed and a civil penalty of $500 was assessed.
Deficiencies (1)
Staff (S1) working in the facility without fingerprint clearance as required by Health and Safety Code Section 1569.17(b).
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ollie Vance | Administrator | Met with Licensing Program Analysts during the visit and was informed about the deficiency and penalty |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 44
Deficiencies: 1
Date: Dec 30, 2022
Visit Reason
An unannounced case management inspection was conducted in response to an incident report submitted by the facility regarding a resident who tried to leave the facility multiple times and was mistreated by staff.
Complaint Details
The visit was complaint-related due to an incident report about staff mistreatment of a resident. The complaint was substantiated as four staff members were found to have treated the resident without dignity and were terminated.
Findings
The investigation found that four staff members treated a resident without dignity by taking off his shirt and locking him outside, which posed an immediate health and safety risk. The staff involved were terminated and an in-service training was conducted.
Deficiencies (1)
Failure to accord dignity to residents in personal relationships with staff, evidenced by four staff members treating a resident without dignity.
Report Facts
Deficiency Type A: 1
Capacity: 44
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ollie Vance | Administrator | Facility administrator who met with Licensing Program Analyst and provided information about the incident and staff termination |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced case management inspection and investigation |
| Sarah Yip | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 44
Deficiencies: 1
Date: Sep 14, 2021
Visit Reason
The visit was conducted due to an incident report received on 09/03/2021 regarding a resident (R1) who left the facility unassisted on 09/02/2021 and was later found outside by a police officer without injury.
Complaint Details
The visit was complaint-related based on an incident report of a resident leaving the facility unassisted. The deficiency was substantiated as the resident was found outside unassisted despite cognitive impairment.
Findings
The Licensing Program Analyst conducted a wellness check and observed the resident without injury. An inspection of egress doors and alarms found no malfunction. The Executive Director conducted staff training to ensure doors are locked and surroundings checked when alarms sound. A deficiency was cited for failure to provide adequate care and supervision as the resident was able to leave unassisted despite cognitive impairment.
Deficiencies (1)
Failure to provide basic services including care and supervision, as resident R1 with mild cognitive impairment was found outside the facility unassisted.
Report Facts
Capacity: 44
Census: 31
Deficiencies cited: 1
Plan of Correction Due Date: Sep 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Rubio | Executive Director | Interviewed during inspection and responsible for staff training related to deficiency |
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Sarah Yip | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Routine
Census: 26
Capacity: 44
Deficiencies: 0
Date: May 21, 2021
Visit Reason
An unannounced infection control site visit was conducted as part of the required 1-year inspection.
Findings
The facility was found to have adequate COVID-19 infection control measures including PPE supply, signage, and screening procedures. No deficiencies were cited, but an advisory note was issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the unannounced infection control site visit. |
| Grace Sandoval | Administrator | Met with Licensing Program Analyst during the visit. |
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