198602069-2-9-2022-11-AS-JHAD-CCHNL4-20220314103254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:14:42 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
01/10/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220110154428

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: 113	DATE:	02/09/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administraor Peggy Clark		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow quarantine procedures for COVID-19

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/09/2022 around 01:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted face to face with Administrator Peggy Clark.

The Investigation consisted of the following: On 01/12/2021 LPA Calderon interviewed Administrator(S1) and S2 conducted a tour of the physical plant. On 01/11/2022 LPA Calderon interviewed W1 for complaint. On 02/08/2022 LPA Calderon interviewed S2-S5 and on 02/09/2022 LPA Calderon interviewed R1- R5. On 02/07, 02/08, 02/09/2022 LPA Calderon noted the actions of facility regarding C19 process.

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: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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 2

Control Number 11-AS-20220110154428

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: 02/09/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility did not follow quarantine procedures for COVID-19
It is alleged that the Facility did not follow quarantine procedures for COVID-19. On 01/12/2022 witness 1 who stated that the facility was not following C19 regulations and noted staff not wearing masks and other PPE while inside the facility. On 01/11/2022 and 02/08/2022 LPA Calderon interviewed S1-S6 who stated that they follow all DPH and DSS process regarding C19. On 02/09/2022 LPA Calderon interviewed R1-R5 who stated that all staff wear masks and other PPE supplies while inside the facility. On 02/07,02/08, and 02/09/2022 LPA Calderon noted that facility is on lock down, that all staff wear masks, shields and gowns and there is signage all over the facility regarding the use of PPE’s. LPA Calderon did not see any staff nor resident not use a mask while in the common arears.

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 in person for records.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2