198602069-6-23-2022-11-AS-JHAD-CFT2CH-20220627171647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/19/2021
Date Signed: 06/23/2022 03:30:50 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
02/08/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210208123416

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:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	ADMINISTRATOR LESLEY FIGUEROA		TIME COMPLETED:	10:47 AM

ALLEGATION(S):

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Administrator did not keep responsible party appraised of resident care.
Resident was not appropriately assessed.
Facility staff failed to report an incident
Staff failed to assist in the administration of medication.
Staff falsified records.
Facility staff failed to adhere to the admission agreement

INVESTIGATION FINDINGS:

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On 04/19/2021 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 02/16/2021 LPA Calderon interviewed (S1) and conducted a tour of the physical plant. On 2/23/2021 LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), medical records, Physicians Report and Medication list). On 2/23/2021 LPA Calderon interviewed (W1). On 2/23/2021 LPA Calderon interviewed S2 and on 3/1/2021 LPA Calderon interviewed S3-S6. On 2/26/2021 LPA Calderon reviewed 2nd round of medical records for R1. ON 03/01/2021 LPA Calderon interviewed R2 – R10 for complaint.

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: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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 4

Control Number 11-AS-20210208123416

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: 04/19/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Administrator did not keep responsible party appraised of resident care.
It is alleged on facility administrator failed to keep responsible party appraised of resident care. On 02/23/2021 witness 1 stated that facility administrator did not keep W1 informed of resident care. On 02/16/2021 LPA Calderon interviewed S1 who stated W1 call resident R1 family and kept them informed of medical status of R1. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did always keep witness 1 informed and R1 medical status was provided to S1 to document R1 medical file. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept them informed of their medical status and kept their families informed. R2-R10 were informed daily of their medical status.

Allegation: Resident was not appropriately assessed.
It is alleged on facility that resident was not appropriately assessed while in care. On 02/23/2021 W1 stated that S1 did not assess R1 prior to moving into facility. On 02/26/2021 LPA Calderon reviewed R1 medical records which included needs and service plan, physician report. The report stated that level 4 extensive care and assistance including allowable health, helps bathing, dressing, toileting, brushing teeth, taking medication, emotionally unstable, inappropriate behavior, possible hostility, dementia. On 3/1/2021 LPA Calderon interviewed S2-S6 who stated R1 was assessed prior to moving into the facility and a copy of the assessment was given to R1 family. On 03/01/2021 LPA Calderon interviewed R2 – R10 who stated that they were provided assessment prior to coming into the facility to live.

Allegation: Facility staff failed to report incident.
It is alleged on facility staff failed to report an incident while in care. On 02/23/2021 W1 stated that S1 did not keep W1 family informed of resident falling to the ground while in care. On 02/16/2021 LPA Calderon interviewed S1 who stated that S1 staff did call W1 family regarding R1 fall and they generated a LIC624 to make sure the exact facts of the fall were known. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did keep W1 family informed of R1 medical status and fall and that they also advised S1 of resident medical status. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept their family informed of any fall while in care

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20210208123416

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: 04/19/2021

NARRATIVE

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Allegation: Staff failed to assist in the administration of medication.
It is alleged on facility staff failed to assist in the administration of medication of residents while in care. On 02/23/2021 W1 stated that facility staff did not help residents with their medication. On 02/16/2021 LPA Calderon interviewed S1 who stated staff did assess residents with their medication and give medication to residents and document residents MAR. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did assist residents with their medications and document residents MAR, but some residents take their own medication without staff help. On 3/1/2021 LPA Calderon interviewed R2-R10 who all stated staff gave their medication on time with no mistakes, some state that they take their own medication with no staff assistance.

Allegation: Staff falsified records.
It is alleged on facility staff falsified records of resident while in care. On 02/23/2021 W1 stated that facility administrator gave W1 a blank medication list and then changed information and gave W1 other medical paperwork. On 02/16/2021 LPA Calderon interviewed S1 who stated S1 gave W1 medical records for R1 which were correct. S1 stated S1 staff gives the medication on time and any errors are written down by administrator and the resident MAR is updated. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that R1 MAR could not be changed after final entry and no one they know made any changes. Staff state that no one has asked them to change the MAR for R1 or alter any medical records and if this had happened, they would inform DSS. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept them informed of their medical status and kept their families informed and any time they requested medical records they were given the paperwork without changes. R2 – R10 state they have no knowledge of any staff or person falsified records.

Allegation: Facility staff failed to adhere to the admission agreement.
It is alleged on facility administrator failed to keep responsible party appraised of resident care under the admission agreement. On 02/23/2021 W1 stated that facility administrator did not keep W1 informed of changes to the admission agreement. On 02/16/2021 LPA Calderon interviewed S1 who stated S1 went over the admission agreement with W1 prior to signing the form and that any change to the admission agreement was done in front of W1 and W1 family and all signed the agreement. S1 states that a copy was given to W1 family for their records. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that administrator did go over admission agreement with W1, but staff does not have any information on this matter. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that any change to their admission agreement is signed by S1 and the resident or family and they are given a copy.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20210208123416

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: 04/19/2021

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	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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4