198602069-4-15-2021-11-AS-JHAD-CDW33Y-20220427175419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/15/2021
Date Signed: 04/15/2021 02:44:41 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
03/23/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210323085831

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: 107	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	ADMINISTRATOR LESLY FIGUEROA		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not prevent residents from engaging in a physical altercation
Facility staff did not prevent resident from exposing themselves

INVESTIGATION FINDINGS:

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On 04/15/2021 around 1:00 PM Licensing Program Manager (LPM) and 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 Lesly Figueroa.

The Investigation consisted of the following: On 04/15/2021 around 12:00 noon LPM Hammond and LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 3/17/2021 LPA obtained copies of Staff and Resident rosters, physicians report. On 2/23/2021 LPA Calderon interviewed Resident 1. On 3/12/2021 LPA Calderon interviewed S2-S6 and on 3/12/2021 LPA Calderon interviewed R1- R10. On 03/29/2021 interviewed administrator for complaint.

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: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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 3

Control Number 11-AS-20210323085831

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: 04/15/2021

NARRATIVE

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Allegation: Facility staff did not prevent residents from engaging in a physical altercation
It is alleged R1 physical assaulted R2 while in care of the facility On. 03/23/2021 LPA Calderon interviewed R1 who confirmed R2 punched him in the face and was given a black eye by R2. R1 confirms he did not call the police and did not tell the facility administrator regarding the assault. On 3/25/2021 LPA Calderon interviewed R2 who denied punching R1 in the eye and does not understand why R1 has any issue with him. On 03/25/2021 LPA Calderon interviewed R3-R10 all confirm issues with R2 and confirms R1 and R2 have had verbal altercations in the past. On 03/25/2021 and 4/5/2021 LPA Calderon interviewed S3- S6 who all confirm that R1 and R2 were good friends, played cards and smoked cigarettes and do not know if R2 gave R1 a black eye. On 03/29/2021 LPA Calderon interviewed S1 who confirmed R1 claimed R2 punched him in the eye and gave her a color photo of his eye, but she did not file any SIR report.

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 for records.

On 03/22/2021 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 reporting party (R1). On 3/17/2021 LPA Calderon interviewed S4 and on 3/22/2021 LPA Calderon interviewed S2- S5. On 03/22/2021 LPA Calderon interviewed R2 – R10. On 03/29/2021 LPA Calderon interviewed administrator for complaint.

The investigation revealed the following:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210323085831

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: 04/15/2021

NARRATIVE

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Allegation: Facility staff did not prevent resident from exposing themselves.
It is alleged on Facility staff did not prevent resident from exposing themselves. On 03/23/2021 witness stated that R1 and R2 exposed themselves to each other persons. On 03/23/2021 LPA Calderon interviewed R1 who stated R2 exposed himself to R1. On 3/25/2021 LPA Calderon interviewed R2 who denied exposing himself to anyone in the facility. On 03/25/2021 LPA Calderon interviewed R3-R10 who had no knowledge of R2 exposing himself to anyone in the facility, but, R1 and R2 have had verbal altercations in the past. On 03/25/2021 and 4/5/2021 LPA Calderon interviewed S3- S6 who all stated that R1 and R2 were good friends, played cards and smoked cigarettes and do not know if R2 exposed himself to R1 or any other resident. On 03/29/2021 LPA Calderon interviewed S1 who stated she saw R2 expose himself to the patio area but does not know if R2 exposed himself any staff or residents.

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 ail for records.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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