198602069-7-8-2021-11-AS-MVAO-C8VNQV-20211118094034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 07/08/2021
Date Signed: 07/08/2021 02:15:24 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
04/12/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210412091544

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	LESLY FIGUEROA		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 116	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	10:44 AM

ALLEGATION(S):

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Bathroom leak came through the floor into a resident's room.

INVESTIGATION FINDINGS:

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On 07/08/2021 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 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 4/21/2021 LPA obtained copies of Staff and Resident rosters, physicians report. On 4/13/2021 LPA Calderon interviewed reporting party (RP). On 4/15/2021 LPA Calderon interviewed S2-S7 and on 4/15/2021, 04/20/2021 LPA Calderon interviewed R1- R10 for complaint. On 07/01/2021 LPA Calderon interviewed S8 for complaint

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 11-AS-20210412091544

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: 07/08/2021

NARRATIVE

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Allegation: Bathroom leak came through the floor into a resident's room.
It is alleged Bathroom leak came through the floor into a resident's room. On 04/13/2021 Reporting Party (RP) stated that R1 room was flooded by a water leak from the room above her floor. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could confirm that there was water leak in the room above R1 room, but that the leak had been repaired. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm the water leak in the room above R1 room, but no one was injured. On 04/20/2021 LPA Calderon interviewed R2-R10 all state there are water leaks all over the facility, but no one had any knowledge of the leak in R1 room.

Based on LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (8) and Chapter (6) are being cited on the attached LIC9099D.

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
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

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 11-AS-20210412091544

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/08/2021 Section Cited CCR 87303(A)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to have bathroom water pipes checked on a monthly basis and will provide infrormation to DSS
	8 9 10 11 12 13 14	Based on interviews and observations LPA confirmed that there was a water leak which came from another bathroom on the floor above. Staff confirmed a water leak and damage to resident room which poses a potential health, safety or personal rights risk to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
04/12/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210412091544

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	LESLY FIGUEROA		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 116	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	10:44 AM

ALLEGATION(S):

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9

Resident was pushed causing injury.
Bathroom leak flooded the kitchen.
Hygiene care of residents

INVESTIGATION FINDINGS:

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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: 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.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20210412091544

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: 07/08/2021

NARRATIVE

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Allegation: Resident was pushed causing injury.
It is alleged Resident was pushed causing injury. On 04/13/2021 Reporting Party (RP) stated that R1 was pushed off her bed by another employee. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could not confirm that any staff member pushed or attacked R1 while she was sitting on her bed. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 no employee had knowledge of any staff pushing a resident off their bed onto the floor. On 04/20/2021 LPA Calderon interviewed R2-R10 all did not have any proof that staff pushed R1 off her bed. On 04/20/2021 interviewed R1 who confirmed staff did not push off the bed, but she rolled off the bed when staff turned her on her side to clean her and she kept going and fell to the floor. On 04/21/2021 received and reviewed all facility paperwork for R1, there is no medical record of R1 falling or being injured from a fall from her bed. On 07/01/2021 LPA Calderon interviewed S8 who confirmed she rolled R1 onto her side to start cleaning her body and R1 kept going and R1 fell to the floor.
Allegation: Bathroom leak flooded the kitchen.
It is alleged Bathroom leak flooded the kitchen. On 04/13/2021 Reporting Party (RP) stated that R1 room was flooded by a water leak from the room above her floor and that this water flooded the kitchen area. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could confirm that there was water leak in the room above R1 room, but that the leak had been repaired and never touched the kitchen. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm the water leak in the room above R1 room, but no information on a flood in the kitchen area. On 04/20/2021 LPA Calderon interviewed R2-R10 all state there are water leaks all over the facility, but no one had any knowledge of the leak in the kitchen. On 04/22/2021 LPA Calderon inspected the kitchen area and could find no signs of any water damage.
Allegation: Hygiene care of residents
It is alleged Hygiene care of residents. On 04/13/2021 Reporting Party (RP) stated that staff missed helping clean himself. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who confirmed R1 was capable of cleaning himself. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm staff takes care of residents that need help taking a shower. On 04/20/2021 LPA Calderon interviewed R2-R10 all state that they do not need help from staff cleaning or showering.

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.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
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

LIC9099 (FAS) - (06/04)

Page: 3 of 5