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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:57:54 PM

Substantiated


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
01/18/2022 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220118164314
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: 108DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Peggy ClarkTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Resident does not receive medication as prescribed.
INVESTIGATION FINDINGS:
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2
3
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5
6
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9
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11
12
13
Licensing Program Analyst/Retired Annuitant (LPA/RA: Elizabeth Ceniceros) conducted an unannounced subsequent visit to the facility at 8:00 a.m. and was greeted by Asst. Administrator (A2: Veronica Gomez); as Administrator (A1: Peggy Clark) was unavailable at the time. LPA/RA Ceniceros spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA Ceniceros that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Analyst (LPA) Troy Agard conducted the unannounced 10-Day visit on 01/21/22. During today’s visit, LPA/RA Ceniceros obtained Incident Reports (dated 12/28/21, 12/30/21), hospital visit information (dated 12/31/21), updated resident roster, facility staff roster & work schedules. LPA/RA Ceniceros toured the facility to inspect the medication room and mail distribution; observed the med room and medication administration records (January 2022 & April 2022); conducted facility staff (S1-S8) interviews at 9:30 a.m. and residents (R1-R8) at 11:00 a.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 5
Control Number 11-AS-20220118164314
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: 04/12/2022
NARRATIVE
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Regarding Allegation #3: this investigation revealed that the medication “Oxycodone” is a PRN and is to be administered “three (3) times a day as needed” to the resident. A review of the resident’s medication administration record (MAR) for the month of January 2022 did not document that the resident was administered the medication (Oxycodone) on 01/13/22, 01/18/22, 01/20/22, 01/24/22, 01/25/22, 01/29/22, 01/31/22 as stated by the complainant. The medication (patch) “Fentanyl” is to be administered every 72 hours. A review of the resident’s MAR for month of January 2022 documented Resident #1 was not administered the medication patch (Fentanyl) at 8:00 a.m. on 01/04/22, 01/07/22, 01/10/22, 01/13/22, 01/19/22, 01/25/22, 01/28/22, 01/31/22. Upon conducting a medication review, the medication (Fentanyl) should be administered at “bedtime” not at 8:00 a.m. (photo). The medication “Methadone” is to be administered “every six (6) hours”. A review of the resident’s MAR for the month of January 2022 documented Resident #1 was not administered the medication (Methadone) on 01/01/22, 01/02/22, 01/08/22, 01/15/22, 01/16/22, 01/22/22, 01/23/22, 01/29/22, 01/30/22 every six (6) hours. In addition, the medication (Methadone) was not administered on 01/03/22, 01/04/22, 01/09/22, 01/10/22, 01/11/22, 01/17/22, 01/18/22, 01/24/22, 01/25/22, 01/31/22 at 6:00 p.m. A review of the resident’s MAR for January 2022 documents the resident was administered the medication “Gabapentin” on 01/31/22 at 8:00 a.m. and 12:00 p.m. The medication “Tramadol” was not administered to Resident #1 on 01/29/22 at 12:00 p.m. or 2:00 p.m. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority replied that they have not received complaints from residents regarding not receiving their prescribed medication(s) by the med techs. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8); and, the majority reported that they have not had any areas of concern with their prescribed medications being administered by the med techs.

Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has been met; therefore, the allegation of MEDICATION: Resident does not receive medication as prescribed is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies were observed and citations issued (ref. LIC 9099D).

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator (Peggy Clark).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
01/18/2022 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220118164314

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: 108DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Peggy ClarkTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide proper notification of rate increase.
Staff open resident's mail.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst/Retired Annuitant (LPA/RA: Elizabeth Ceniceros) conducted an unannounced subsequent visit to the facility at 8:00 a.m. and was greeted by Asst. Administrator (A2: Veronica Gomez); as Administrator (A1: Peggy Clark) was unavailable until 9:00 a.m. LPA/RA Ceniceros spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA Cenicerso that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Analyst (LPA) Troy Agard conducted the unannounced 10-Day visit on 01/21/22. During today’s visit, LPA/RA Ceniceros obtained the following documents: updated resident roster, facility staff roster & work schedule (January 2022). LPA/RA Ceniceros toured the facility to inspect the facility’s mail room (photo); obtained mail room's "Medication Drop Off Log" and "Packages Received and Delivered to Residents Room"; observed process for facility's daily mail distribution; conducted interviews with facility staff (S1-S8) at (TIME) and residents (R1-R8) at (TIME).

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20220118164314
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: 04/12/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed in Resident #1’s administrative file, documentation received by the resident as follows: Facility letter (dated 12/01/21) regarding “Rent Increase Notice” effective 01/01/2022; Notice from Archangel Care Coordination Agency regarding new SSI/SSP rates for non-medical out-of-home care (NMOHC), effective 01/01/22; Informational Sheet from Libertana Home Health regarding new SSI/SSP rates for 2022. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority indicated that they had not received complaints from residents regarding them not receiving a notice of rent increase, effective 01/01/22. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8) who replied that over the years, the facility has increased rent rates on an annual basis; and, they did receive their letter regarding the rent increase, effective 01/01/22.

Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Facility did not provide proper notification of rate increase is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1’s USPS Mail - upon receipt from the USPS mail carrier, the mail is sorted and distributed to residents accordingly. LPA/RA observed the facility’s process upon receiving the mail delivery (approx) 11:30 a.m. is sorted by the receptionist and distributed by the caregivers to the residents by room number. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority stated that they had not received complaints from residents regarding their mail having been opened by facility staff. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8) who replied that their daily mail has not ever been opened by facility staff.

Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff open resident’s mail is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to Administrator (Peggy Clark).
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220118164314
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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2022
Section Cited
CCR
87465(c)(2
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Incidental, Medical, and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by: Meds not given to R1: Oxycodone (3x a day as needed) on 01/13/22, 01/18/22, 01/20/22, 01/24/22, 01/25/22, 01/29/22.
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Licensee/Administrator agreed to comply with the Regulations and conduct an in-service training for all facility staff administering medication to the residents. Licensee/Administrator agreed to submit their verification of completion to CCLD/El Segundo ASC Office by POC due date 04/19/22.
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(Cont) Fentanyl (every 72 hours) on 01/04/22, 01/07/22, 01/10/22, 01/19/22, 01/25/22, 01/28/22, and 01/31/22 at 8:00 a.m. Methadone (every 6 hours) on 01/01/22, 01/02/22, 01/08/22, 01/15/22, 01/16/22, 01/22/22, 01/23/22, 01/29/22, 01/30/22.
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Type B
04/12/2022
Section Cited
CCR
87465(h)(6)(A-F)
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Incidental, Medical, and Dental Care: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained
for at least one year and includes:

This requirement is not met as evidenced by:
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A review of R1's MAR for the month of January 2022 did not document (staff initials) Oxycodone, Fentanyl, Methadone, Tramadol, Gabapentin were administered to the resident.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5