198602069-5-20-2022-11-AS-JHAD-CF6VNU-20220607163543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/29/2022
Date Signed: 05/20/2022 09:37:24 AM

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
03/26/2021 and conducted by Evaluator Jose Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210326105645

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:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	10:31 AM

ALLEGATION(S):

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Resident was double-charged for services.

INVESTIGATION FINDINGS:

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THIS REPORT SUSPERCEDES REPORTED DATED 07/08/2021 TO UPDATE INVESTIGATION FINDINGS

On 07/08/2021 around 10:00 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 02/16/2021 LPM Janae Hammond and LPA Jose Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 3/26/2021 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months, admission agreement, emails between POA, Ombudsman and administrator, book keepers’ records for R1. On 3/29/2021 and 07/01/2021 On 07/06/2021 LPA Calderon interviewed S1-S6.

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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210326105645

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: 04/29/2022

NARRATIVE

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The investigation revealed the following:

Allegation: Resident was double-charged for services.
On 7/8/2021, LPA interviewed S1 regarding the allegation. S1 stated she is not aware of any residents being double charged and there is no record of any double charges documented. On 7/6/2021, LPA interview S2 and he stated no residents were double charged. On 07/06/2021 LPA Calderon Interviewed R1-R6 who were not aware of the allegation. On 7/01/2021 LPA Calderon Interviewed S3-S6 all stated they were not aware of the allegation. On 04/21/2021 LPA Calderon reviewed facility paperwork for R1 to include the admission agreement which did not support that the licensee double charged the resident.

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.

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

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