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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 07/08/2021
Date Signed: 07/09/2021 08:23:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:RACHEL STREICHERFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 116DATE:
07/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Peggy ClarkTIME COMPLETED:
11:04 AM
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Proof of Corrections(POC) visit and met with Designated Administrator Peggy Clark, and discuss the purpose for todays visit which is to verify/confirm that the deficiencies cited during the Required 1-Year visit on 06/10/2021 have been corrected/cleared.

During todays visit LPA confirmed that the following deficiencies/Title 22 Regulations cited on 06/10/2021 were not corrected:
87463(c) Reappraisals: The licensee failed to ensure that reappraisal meetings were conducted once every 12 months, 5 out of 10 resident records reviewed did not indicate that needs and services plan meetings were conducted within the last 12 months which poses a potential health and safety risk to clients in care.
87303(a) Maintenance and Operation: The licensee failed to ensure that the facility is safe and in good repair. LPA observed that the floor inside elevator near bedroom number 143 is cracked, which poses a potential health and safety risk to clients in care.
87705(c)(5) Care of Persons with Dementia: The licensee failed to ensure that an annual medical assessment was conducted for residents with dementia, a medical assessment was not conducted for resident number 5 within the last 12 months which poses a potential health and safety risk to clients in care.

Civil penalties are being assessed, please see LIC421FC. Exit interview conducted and a copy of this report was given to Assistant Program Manager Peggy Clark.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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