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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 07/08/2021
Date Signed: 01/07/2022 10:26:08 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
06/14/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210614154902
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: 116DATE:
07/08/2021
UNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:ADMINISTRATOR PEGGY CLARKTIME COMPLETED:
11:07 AM
ALLEGATION(S):
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Staff did not provide timely medical assistance.
Resident developed an infection on hand
INVESTIGATION FINDINGS:
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On 07/08/2021 around 12:00 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 06/15/2021 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed witness for complaint. On 06/15/2021 LPA Calderon interviewed R1 for complaint. On 06/15/2021 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 and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed medical paperwork for R1.


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: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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-20210614154902
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: 07/08/2021
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not provide timely medical assistance.
On 06/15/2021 LPA Jose Calderon interviewed Administrator (S1) who stated R1 injured R1 right index finger while using R1 wheel chair. S1 states that R1 was assessed by RN when they became aware of the injury and then transported to the hospital for evaluation. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint, all state they were aware of R1 injury to the finger, but also state that they took care of R1 needs, but R1 finger was not getting better, and R1 was moved to the hospital for more care. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed Witness (W1) and W1 stated that when W1 visited R1, W1 noticed gangrene on the right index finger. W1 took R1 to Kaiser hospital. On 06/15/2021 LPA Calderon interviewed R1 for complaint, he states an unknown person pushed R1 down a ramp inside the facility and R1 injured his finger on his wheel chair. On 06/15/2021 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 and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed Kaiser Medical Records for R1. The review of the medical records revealed that R1 did not have gangrene or an infection. Based on interviews conducted and records the facility provided basic first aid for an injury and R1 was taken to the hospital when the injury worsened.

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

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20210614154902
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: 07/08/2021
NARRATIVE
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Allegation: Resident developed an infection on hand
On 06/15/2021 LPA Jose Calderon interviewed Administrator (S1) who stated R1 injured R1 right index finger while using R1 wheel chair. S1 states that R1 was assessed by RN and then transported to the hospital for evaluation. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint, all state they were aware of R1 injury to the finger, but also state that they took care of R1 needs, but R1 finger was not getting better, and R1 was moved to the hospital for more care. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed Witness (W1) and W1 stated that when W1 visited R1, W1 noticed gangrene on the right index finger. W1 took R1 to Kaiser hospital. On 06/15/2021 LPA Calderon interviewed R1 for complaint, he states an unknown person pushed R1 down a ramp inside the facility and R1 injured his finger on his wheel chair. On 06/15/2021 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 and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed Kaiser Medical Records for R1. The review of the medical records revealed that R1 did not have gangrene or an infection.

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

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3