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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 07/01/2021
Date Signed: 07/01/2021 04:10:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 116DATE:
07/01/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Peggy Clark TIME COMPLETED:
04:20 PM
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Licensing Program Analysts (LPAs) Nicol Wesley Luis Mora conducted an unannounced Proof of Corrections(POC) visit and met with Assistant Program Manager Peggy Clark, and discuss the purpose for todays visit which is to verify/confirm that the deficiency cited during the case management visit on 06/11/2021 have been corrected/cleared.

1). Type B, 87506(d)(e)-Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement has not been met as required: During todays visit, LPAs requested to review resident #1's and was informed that they were not available. They were locked in a location and the Administrator had the key. **This deficiency was corrected on 07/01/21(during todays visit).**

There were no deficiencies cited during todays visit.

Exit interview conducted and a copy of the report was given to Assistant Program Manager Peggy Clark.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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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