198602069-8-19-2021-11-AS-MVAO-C6FMPQ-20210901094732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:14:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210729083924

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 116	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	10:42 AM

ALLEGATION(S):

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Resident engaged in a physical altercation with another resident resulting in bruising.
Resident’s personal belongings are stolen.

INVESTIGATION FINDINGS:

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On 08/19/2021 around 11:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark.

The Investigation consisted of the following: On 08/05/2021 LPA Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 8/05/2021 LPA Calderon obtained copies of Staff and Resident rosters, physicians report, needs and service plan for R1-R2. On 8/11/2021 LPA Calderon interviewed witness(W1). On 8/05/2021 LPA Calderon interviewed S2-S4 and interviewed R2- R3. On 08/11/2021 LPA Calderon called R1 who hung up on LPA. On 8/11/2021 received and reviewed R1 and R2 facility paperwork.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210729083924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
	VISIT DATE: 08/19/2021

NARRATIVE

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Allegation: Resident engaged in a physical altercation with another resident resulting in bruising.
It is alleged on Resident engaged in a physical altercation with another resident resulting in bruising. On 08/05/2021 interviewed S1 who confirmed the photo of R1 with a black eye was from March 2021 and was a old picture. S1 states that R1-R2 did not advise her of any altercation and that no SIR report was filed. S1 confirms the police did not come to the facility and investigate any assault. On. 8/05/2021 LPA Calderon interviewed S2-S4 who all confirmed to issues between the two residents. On 08/05/2021 LPA Calderon interviewed R2-R3 both suggest R1 made up this story and no one ever assaulted R2. On 08/11/2021 LPA Calderon tried to interview R1, but R1 who failed to give statement and hung up on LPA Caldron. On 08/11/2021 LPA Calderon received and reviewed medical records for R1-R2, but records suggest easily signs of dementia and could not or would not give a statement

Allegation: Resident’s personal belongings are stolen.
It is alleged on Resident’s personal belongings are stolen... On 08/05/2021 interviewed S1 who confirmed that no report was made by R1 to the administrator, staff or the police on stolen items. S1 confirms that R1-R2 are good friends and there has been no issues between to 2 men. On 08/08/2021 LPA Calderon interviewed R2-R3 both confirm no one has ever stolen items in their room. On 08/11/2021

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A telephonic exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided via email for records.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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