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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 03/29/2021
Date Signed: 04/02/2021 01:55:31 PM

Unsubstantiated


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
02/24/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210224095654
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 107DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:ADMINISTRATOR LESLY FIGUEROATIME COMPLETED:
03:47 PM
ALLEGATION(S):
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8
9
Staff did not prevent Resident from attacking another resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/29/2021 around 3pm 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 telephonically via face time with Administrator Lesly Figueroa.

The Investigation consisted of the following: On 03/17/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 3/22/2021 LPA obtained copies of Staff and Resident rosters. On 3/8/2021 LPA Calderon interviewed Resident #1 (R1). On 3/17/2021 LPA Calderon interviewed Staff #4 (S4) and on 3/22/2021 LPA Calderon interviewed Staff S2-S3 and S5. On 03/22/2021 LPA Calderon interviewed Residents #2-10 (R2 – R10).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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
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
02/24/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210224095654

FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 107DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:ADMINISTRATOR LESLY FIGUEROATIME COMPLETED:
03:47 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is harassing another resident
Staff did not prevent a resident from speaking inappropriately towards resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/29/2021 around 3pm 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 telephonically via face time with Administrator Lesly Figueroa.

The Investigation consisted of the following: On 03/17/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 3/22/2021 LPA obtained copies of Staff and Resident rosters. On 3/8/2021 LPA Calderon interviewed Resident #1 (R1). On 3/17/2021 LPA Calderon interviewed Staff #4 (S4) and on 3/22/2021 LPA Calderon interviewed Staff S2-S3 and S5. On 03/22/2021 LPA Calderon interviewed Residents #2-10 (R2 – R10).

The investigation revealed the following:

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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-20210224095654
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: 03/29/2021
NARRATIVE
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Allegation: Resident is harassing another resident.
It is alleged facility staff failed to prevent R6 from harassing R1. On 03/8/2021 R1 stated that R6 verbally abuses him and facility administrator did not prevent the verbal abuse. On 03/17/2021 LPA Calderon interviewed S1, she stated R6 did verbally call R1 abusive names. On 3/17/2021 and 3/22/2021 LPA Calderon interviewed R2-R10 who all state that there were issues between R1 and R6 and that R6 called R1 names. R3-R5 stated R6 was verbally abusive towards them. On 3/22/2021 LPA Calderon interviewed S2- S5 who state that they heard about R6 verbally attacking R1.

The investigation revealed the following:

Allegation: Staff did not prevent a resident from speaking inappropriately towards resident.
It is alleged facility staff failed to prevent R6 from speaking inappropriately towards R1. On 03/8/2021 R1 stated that R6 verbally abuses him and facility administrator did not prevent the verbal abuse. On 03/17/2021 LPA Calderon interviewed S1, she stated R6 did verbally call R1 abusive names. S1 stated she spoke with R6 about the verbal abuse once. On 3/17/2021 and 3/22/2021 LPA Calderon interviewed R2-R10 who all stated that R6 called R1 names. R3-R5 stated R6 was verbally abusive towards them. On 3/22/2021 LPA Calderon interviewed S2- S5 who state that they heard about R6 verbally attacking R1.

Based on LPAs 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 6 and Chapter 8 are being cited on the attached LIC 9099D.

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

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210224095654
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: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2021
Section Cited
CCR
87468.1(a)
1
2
3
4
5
6
7
87468.1(a) Personal Rights of Residents in All Facilities...(a) To be accorded dignity in their personal relationship wth staff, residents or other persons. This requirement is not met as evidenced by.
1
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3
4
5
6
7
During administrator interview, confirmed facility will train staff to address abuse from residents and report to administrator. Administrator to email proof to LPA training.
8
9
10
11
12
13
14
Based on observations and interviews staff and residents confirm R6 was abusive to R1 and other residents. Staff did not correct abuse from R6 which poses an immediate Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/09/2021
Section Cited
CCR
87468.1(a)
1
2
3
4
5
6
7
87468.1(a) Personal Rights of Residents in All Facilities...(a) To be accorded dignity in their personal relationship wth staff, residents or other persons. This requirement is not met as evidenced by
1
2
3
4
5
6
7
During administrator interview, confirmed facility will train staff to address abuse from residents and report to administrator. Administrator to email proof to LPA training.
8
9
10
11
12
13
14
Based on observations and interviews staff and residents confirm R6 was abusive to R1 and other residents. Staff did not correct abuse from R6 which poses an immediate Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210224095654
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: 03/29/2021
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
The investigation revealed the following:

Allegation: Staff did not prevent Resident from attacking another resident.
It is alleged facility staff failed to prevent R6 from attacking R1. On 03/8/2021 R1 stated that R6 physically attacked him and facility administrator knew about the attack and did not prevent the physical attack. On 03/17/2021 LPA Calderon interviewed S1 that stated she was informed by R1 that he was attacked by R6 but there were no witnesses. On 3/17/2021 and 3/22/2021 LPA Calderon interviewed R2-R10 who all confirm that there were issues between R1 and R6. R2-R10 cannot confirm if R6 attacked R1.On 3/22/2021 LPA Calderon interviewed S2- S5 who state that they have no knowledge of R6 physically attacking R1.

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 Lesly Figueroa, and a hard copy was provided via email for records.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5