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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 08/03/2021
Date Signed: 08/03/2021 05:04:05 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:PEGGY CLARKFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 115DATE:
08/03/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Peggy Clark TIME COMPLETED:
02:45 PM
NARRATIVE
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***This LIC 809 and LIC 809D supersedes the LIC 809 and LIC 809D that was created on 06/11/2021.***

Licensing Program Analysts (LPAs) Nicol Wesley and Nune Margaryan conducted a case management visit and met with Assistant Program Manager Peggy Clark and discuss the purpose for todays visit. During todays visit, LPAs were attempting to complete a subsequent complaint visit complaint control #28-AS-20200220130538, and requested to review the facility file for resident #1. LPAs were informed that the Administrator Lesly Figueroa was not present in the facility so the staff was not able to gain access to the residents files.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8) on the LIC 809D.

Exit interview conducted, appeal rights explained 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: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited

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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
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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 availble. They were locked in a location and the Administrator had the key which can poses a potential health risk to residents 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.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2021
LIC809 (FAS) - (06/04)
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