Crescent Oaks

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: - Staff failed to prevent client from pushing another client

LPA Jeung met with resident care coordinator and acting administrator, interviewed staff, and reviewed client files and staff training records. Copies of relevant documents are provided. An incident occurred on 10/31/25--and Unusual Incident Reports were submitted to CCLD, reporting that client #1 pushed client #2 to the floor, sustaining a closed head injury. Names of staff involved were not included in Report; this information is provided to LPA today. On that day, there were 4 caregivers on work schedule, plus a med tech and housekeeper. LPA interviewed 3 staff who worked on 10/31/25. Staff were unable to prevent client from harming another resident. When client's adverse behavior was observed, staff reacted appropriately to intervene and try to prevent anyone from harm. Based on review of facility and other reports and interviews with staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prthe state’s words, verbatim · CDSS document, Dec 1, 2025 · control 26-AS-20251121154338

Allegation investigated: - Facility staff did not prevent resident from hitting another resident

Based on review of facility and other reports and interviews with staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur. Despite at least ten documented incidents involving client #2 as the instigator of threatening, aggressive or combattive behaviors within 60 days, staff were unable to prevent client from harming another resident. When client's adverse behavior was observed, staff reacted appropriately to intervene and try to prevent anyone from harm. However, client did not have a dedicated caregiver to provide 24/7 supervision. During this investigation, deficiencies of the CA Code of REgulations, Title 22 were observed. See separate FAcility Evaluation Report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 29, 2025 · control 26-AS-20251017113320

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure incontinence care is provided in a timely manner Staff do not ensure residents are kept clean and dry

On 8/11/2025, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit to deliver the findings. LPA met with Adminstrator Joshua Lambengco and explained the purpose of the visit. Regarding the allegations of staff do not ensure incontinence care is provided in a timely manner and staff do not ensure residents are kept clean and dry, RP stated that when he/she has gone down to visit R1 on multiple occasions, RP has found R1 in triple diapers and soaked through in his/her linens. During the interviews, S2 stated that R1 pees a lot so they put double diapers because sometimes R1 takes it off. When R1 takes off the one in the front then there’s another one under. R1 is also hard to get up and bring to the bathroom. It’s easier for them. page 1 of 2 Substantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2025 · control 26-AS-20240619104312

Allegation investigated: Staff did not dispense medication to residents as prescribed Staff did not assist resident with eating

On July31, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Resident Care Coordinator (RCC), Bernadette Kang. The LPA disclosed the purpose of the visit. On 05/05/2025, the department received a complaint with the above two (2) allegations. On 5/12/2025 and 07/08/2025, the department conducted initial investigations at the facility. Regarding the allegation ‘Staff did not dispense medication to residents as prescribed’, the Reporting Party (RP) alleged that the staff did not give R1 and R2 the prescribed pain medication. On 05/12/2025 and 07/08/2025, LPA interviewed six (6) staff members (S1-S3 and S5-S7) and two (2) residents (R3 and R4). Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 31, 2025 · control 26-AS-20250505103401

Allegation investigated: Facility staff did not assist resident with feeding resulting in weight loss

On July31, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Resident Care Coordinator (RCC), Bernadette Kang. The LPA disclosed the purpose of the visit. On 05/23/2025, the department received a complaint with the above one (1) allegation. On 5/28/2025, the department conducted initial investigations at the facility. Regarding the allegation ‘Facility staff did not assist resident with feeding resulting in weight loss’, the Reporting Party (RP) alleged that the R1 was not given food, R1 was hungry, and R1 had been losing weight. On 05/28/2025 and 07/08/2025, LPA interviewed three (3) staff members (S2, S5, and S6), and three (3) residents (R3, R4, and R5). Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 31, 2025 · control 26-AS-20250523161929

Allegation investigated: Staff camouflaged residents’ medication Staff did not ensure call assistance buttons in residents’ rooms were operable

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. Unfoundedthe state’s words, verbatim · CDSS document, May 15, 2025 · control 26-AS-20240510105333

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure the elevator is working properly

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 Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2025 · control 26-AS-20250107125539

Allegation investigated: . Administrator is not on the premises a sufficient number of hours to meet the needs of the residents. 2. Staff are not following infection control practices. 3. Staff are not adhering to proper hand washing practices. 4. Staff do not provide resident with hand washing soap. 5. Staff do not respond to resident's request for assistance.

On 11/07/2024 Licensing Program Analyst (LPAs) Kiran Jain and Grace Donato conducted an unannounced complaint investigation visit and met with Resident Care Coordinator Bernadette Kang. LPAs explained the purpose of the visit. Regarding the allegation that the Administrator is not on the premises a sufficient number of hours to meet the needs of the residents, there is no contact information for the Reporting Party (RP), hence LPA was unable to get more details about this allegation. Based on the staff (S1-S4) interviews conducted on 10/15/2024 with four staff members, , the Administrator (S4) is at the facility for 4 hours per day and in S4’s absence the Resident Care Coordinator (S3) and Med tech (S1) acts as manager on duty. Based on the resident (R1) interview conducted on 10/15/2024, R1 stated that they are satisfied with the Administrator at the facility. Page 1 of 4... Continued on LIC9099-C... Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 7, 2024 · control 26-AS-20241007092911

Allegation investigated: Staff are not ensuring a safe environment for residents in care. Staff are mismanaging resident's medications. Staff are not ensuring that residents are administered their medications as prescribed. Staff are not regularly informing resident's representatives of information related to the care or services for residents in care. Staff are not ensuring that residents have a reasonable ability to receive confidential calls. Staff are not reporting incidents involving residents as required. Staff yell at residents in care.

On 10/30/24, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Joshua Lambengco and explained the purpose of the visit. Regarding the allegations that staff are not ensuring a safe environment for residents in care, staff are not regularly informing resident's representatives of information related to the care or services for residents in care and staff are not reporting incidents involving residents as required, reporting party (RP) stated that ADM keeps information about the care and supervision of residents from loved ones, and misleads them about the resident's care and experiences. ADM doesn't want people to know what is really going on at this facility. Some of the residents that are allowed to live in this facility are very combative and are harassing other residents. For example, about 2 months ago a resident hit another resident which caused a bruise on their shoulder. This incident (and other incidents) was never reported to athe state’s words, verbatim · CDSS document, Oct 30, 2024 · control 26-AS-20230509114956

Allegation investigated: Lack of supervision resulting in resident to resident altercation.

Licensing Program Analyst (LPA) David Marrufo conducted a complaint investigation visit and met with Joshua Lambengco, Administrator (ADM). On 04/30/2024, the Department received a complaint with the above allegation. An initial complaint investigation visit was conducted on 05/09/2024. During visit, LPA Marrufo conducted interviews and obtained copies of resident records. LPA Marrufo requested a police report from local law enforcement on 05/06/2024 using the police report case number provided by the complainant. Local law enforcement responded to LPA Marrufo’s request on 05/06/2024 and stated there was no police report with the provided police report case number. See LIC9099-C for more information. Page 1 of 3. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 13, 2024 · control 26-AS-20240430095729

Allegation investigated: Staff did not provide adequate food service Staff don't respond to residents' call assistance button promptly

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced compliant investigation visit and met with Joshua Lambengco, Administrator (ADM). On 06/03/2024, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint investigation visit on 06/05/2024. The Department cross-reported the complaint to local law enforcement. On 06/04/2024, the Department conducted a telephone interview with a police officer from local law enforcement who visited and toured the facility on 06/04/2024. The police officer stated to have toured the kitchen and observed the refrigerator and observed food of good quality. The police officer stated to have viewed the facility menus and records and was able to see residents being served special diets. See LIC9099-C for more information. Page 1 of 3. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 13, 2024 · control 26-AS-20240603132838

Allegation investigated: Facility did not provide supervision to resident in care, resulting to altercation between residents

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Resident Care Coordinator, Bernadette Kang. On 07/25/2024, the Department received a complaint alleging that the facility did not provide supervision to resident (R1) and (R2) resulting in an altercation between residents. On 08/01/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the staff schedule, resident (R1) – (R2)’s physician’s report, service plan, progress notes, and incident reports. SEE LIC9099-C. Unfoundedthe state’s words, verbatim · CDSS document, Aug 1, 2024 · control 26-AS-20240725150151

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Insufficient staffing to meet resident needs

On 2/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator Ollie Vance. LPA explained the purpose of the visit. Regarding the allegation of insufficient staffing to meet residents’ needs. Reporting party (RP) called about staffing shortage. RP also mentioned that the temporary staff from the agency were sometimes nowhere to be found. LPA Ng conducted interviews with different staff members. Three out of seven staff members interviewed stated that there are occasions where there is insufficient staffing. One staff member, S1, mentioned that usually there were agency staff on duty to help the regulars. But sometimes the agency staff came one to two hours late. Sometimes not showing up at all. There were times that the caregivers could not finish the tasks on time. Another staff member, S2, stated that the management tried to get the agency staff, but no agency staff came though. It was sthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 26-AS-20210816135004

Allegation investigated: Insufficient staffing to meet resident needs

On 2/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator Ollie Vance. LPA explained the purpose of the visit. Regarding the allegation of insufficient staffing to meet resident needs, the reporting party (RP) stated that August 21, 2021, he/she walked into the facility and there were two caregivers for thirty-two residents. LPA Ng conducted interviews with staff members and four out of four mentioned that there is not insufficient staffing in the facility. Two of these staff members, S1 & S2, stated that there are always four caregivers scheduled in a shift. S1 also mentioned that if a staff calls in, management will call the agency to send a replacement. Usually, the replacement could come on time if the staff calls in earlier. Another staff member, S3, mentioned that Med-Techs act as managers on weekends when there is no manager on duty. LPA Donato also observed the facility to bethe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 26-AS-20210824115113

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.