198602069-5-31-2022-11-AS-JHAD-CF6MYB-20220607100116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 02/09/2022
Date Signed: 05/31/2022 11:43:02 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
01/31/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220131135256

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:	09:00 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	09:38 AM

ALLEGATION(S):

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Facility falsified documents.
Facility did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 02/09/2022 around 02:00 PM 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 02/08/2022 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 02/08/2022 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. On 02/02/2022 LPA Calderon interviewed R1 and on 02/07/2022 and 02/08/2022 LPA Calderon interviewed S1-S6. On 02/07/2022 LPA Calderon interviewed R1-R2

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)

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Control Number 11-AS-20220131135256

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

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Allegation: Facility falsified documents.

It is alleged Facility falsified documents. On 02/07/2022 LPA Calderon Interviewed R1 who stated that the facility had altered or changed many of his paperwork, but R1 did not have proof. R2 stated that R2 had reviewed R2 medical paperwork and there was no been changed and R2 did not have any issues with the facility or R2 medical paperwork. On 02/08/2022 LPA Calderon reviewed all facility paperwork for R1 to include the admission agreement, needs and service, physician report, MAR which all state that there were no changes to resident 1 facility paperwork. On 05/31/2022 LPA Calderon interviewed R3 - R10 all state staff had never changed or falsified their medical or facility records.

Allegation: Facility did not safeguard resident's personal belongings.

party. On 02/02/2022 LPA Calderon Interviewed R1 who stated that personal items had been lost or stolen and R1 believes that the cleaning staff had taken R1 items, but R1 did not have any proof. R2 who states that a few months ago R2 had lost $100.00 dollars, or a staff took the money, R2 states that the facility paid her back, and no one has taken or stolen any of R2 personal items. 02/08/2022 LPA Calderon Interviewed S1-S6 all state that the facility does safe guard the personal items of the resident and no staff member would steal or take any resident personal items. On 05/31/2022 LPA Calderon interviewed R3 - R10 all states that no staff member has ever taken or used their personal items and no other resident has ever taken their personal items from their room.

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 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)

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