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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 09/14/2022
Date Signed: 09/21/2022 01:56:15 PM

Substantiated


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
11/17/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20211117133315
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:PEGGY CLARKFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 119DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:ADMINISTRATOR PEGGY CLARKTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained multiple injuries while in care
INVESTIGATION FINDINGS:
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On 9/14/2022, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced subsequent visit to the facility at (TIME) and was greeted by Administrator (S1: Peggy Clark). LPA spoke to S1 prior to entering the facility to conduct a risk assessment. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.
The investigation consisted of the following: Licensing Program Analyst (LPA) Jose Calderon conducted an visit on 11/18/21. LPA initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1: Peggy Clark). LPA requested copies of the following: staff and resident rosters, SIR reports, physician’s report, appraisal/needs and services plan, and all medical records to include any hospital records for Resident #1. A separate investigation was conducted by the Department of Social Services, Investigator Phillipe Miles that included a review of medical records, interview with witnesses, facility staff and medical services staff.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 7
Control Number 11-AS-20211117133315
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: 09/14/2022
NARRATIVE
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Regarding Allegation Resident sustained multiple injuries while in care: Resident #1 was admitted to the facility on 07/24/21. According to R1 Physicians Report R1 was diagnosed (as of 07/21/21) Dementia, Vascular Dementia, History of Stroke, Type II Diabetes, Hypertension, Coronary Artery Disease (CAD) , Lumbar spinal stenosis and Chronic Kidney Disease (CKD). During R1 residing at Palmcrest Grand R1 had 2 falls. On 10/28/2021, Resident #1 (R1) was admitted to College Medical Center for a mechanical fall in the shower at Palmcrest Grand Residence. During evaluation, R1 suffered a closed fracture in one rib, and fracture of transverse process of thoracic vertebra. On 10/29/22, R1 was re-admitted to hospital at Kaiser South Bay Medical Center with a chief complaint of a Fall last night and Rib Pain. R1 was diagnosed with mechanical fall with left 6th posteriorly rib fracture and T7 left transverse process fracture and CT R frontal hematoma. On 11/02/21 R1 was discharged from Kaiser South Bay Medical Center with home health services. On 11/04/21 R1 sustained a second fall and was admitted to Long Beach Memorial on 11/04/21 with a subdural hematoma (brain bleed) due to unwitnessed fall from resident’s bed, to the ground – in a supine position. Resident #1 was not discharged back to Palmcrest Grand Residence.

On 1/5/2022, IB Investigator interviewed Peggy Clark Administrator (S1) regarding the allegation. S1 stated R1 was admitted to the facility July 2021. S1 stated R1 sustained two falls in the facility, first fall October 2021 and the second November 2021. S1 stated after R1 first fall the LVN did not reassess R1 but did increase R1 Safety checks to every 30 minutes as the resident became a fall risk. On 1/5/22, IB Investigator interviewed Veronica Gomez Assistant Administrator (S2) regarding R1. S2 stated R1 was admitted to the facility around August 2021 and assessed with Vascular Dementia and placed in the Memory Care Unit. S2 stated R1 health began to decline, such as, loss of appetite. When R1 did not eat, R1 would feel dizzy, lose balance and has incurred a fall(s). S2 stated after R1 first fall R1 was reassessed and frequency of room checks for R1 was increased to every 15-30minutes.

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

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 11-AS-20211117133315
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: 09/14/2022
NARRATIVE
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At the same time S2 stated their were 6 other residents in Memory Care Unit that required increased supervision. S2 stated the facility should have provided R1 one-on-one supervision or increase R1 level of care” after R1 first fall, “knowing” that R1 became a fall risk. IB investigator interviewed S3-S4. S3 stated R1 did sustain injuries from 2 falls at the facility. S3 stated R1 health had been declining and R1 should have been in a higher level of care. S4 stated the facility knew R1 was fall risk and should have increase R1 care and supervision to possibly a one to one. S4 stated S4 believes R1 needed a higher level of care. LPA reviewed R1 records and did not observe a reappraisal or reassessment of R1 documented following R1 falls. IB investigator/ LPA interviewed Witness (W1) that stated that R1 quality of life changed after the second fall resulting in R1 no longer being able to feed herself, balance, speak coherently and walk without extreme assistance. W1 stated following the first fall Palmcrest Grand had assured they could provide proper care to R1. W1 stated R1 passed away 5 months following the second fall.Based on records reviews and interviews conducted the facility failed to reassess R1 when it was observed R1 had changes in care needs resulting in R1 having falls and sustaining serious injuries from falls.Based on interviews and observations and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained multiple injuries while in care is found to be SUBSTANTIATED.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

During today’s visit a $500 dollar Civil Penalty is assessed.



An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator Peggy Clark.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20211117133315
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87705(C)(5)(A)
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87705:Care of Persons With Dementia; C:Licensees who accept and retain residents with dementia...(5) Each resident with dementia shall have an annual medical assessment ...(A) When any medical assess...This requirement is not met as evidenced by: Licensee/Administrator failed
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Licensee/Administrator agreed to comply with Regulations and conduct in-service training to ensure facility staff have a complete understanding of appropriate care and supervision with residents being left alone (without appropriate supervision). Licensee/Administrator agreed to submit a verification of completion to CCLD/El Segundo ASC Regional Office by POC due date on 09/23/2022.
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Based on interviews, observations and records the licensee failed to tMaintain a medical assessment and re-appraisal which resulted in Resident #1’s multiple falls due to the need for appropriate supervision by staff for safety.
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Type A
09/23/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. The Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...Licensee/Administrator failed to observe or conduct - at least annually - an assessment..
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Licensee/Administrator will review Title 22 Regulations, Section 87466 and submit a detailed written plan on how the facility will document and address changes in the resident(s) condition. This plan is due to the CCLD/El Segundo ASC Regional Office by POC date of 09/23/2022.
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BasBased on interviews, observations and records the licensee failed to observe or conduct - at least annually - an assessment or re-appraisal of Resident #1’s level of care during the time Resident #1 lived at the facility when there were notable changes in R1 car needs.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20211117133315
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87405(D)(1)
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87405 Administrator - Qualifications and Duties: D; By retaining a resident without maintaining a medical assessment... This requirement is not met as evidenced by: Licensee/Administrator did not display knowledge of requirements
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Licensee/Administrator will read Title 22, Section 87405(d)(1) “Administrator – Qualifications and Duties”
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Based on inteviews, observations and records Licensee/Administrator did not display knowledge of requirements for providing care and supervision appropriate to Resident #1 who had a high, fall-risk history.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/17/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20211117133315

FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:PEGGY CLARKFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 119DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:ADMINISTRATOR PEGGY CLARKTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained bruised wrists while in care
INVESTIGATION FINDINGS:
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On 9/14/2022, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced subsequent visit to the facility at (11:00 AM) and was greeted by Administrator (A1: Peggy Clark). LPA spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: Licensing Program Analyst (LPA) Jose Calderon conducted an visit on 11/18/21. LPA initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1: Peggy Clark). LPA requested copies of the following: staff and resident rosters, SIR reports, physician’s report, appraisal/needs and services plan, and all medical records to include any hospital records for Resident #1. A separate investigation was conducted by the Department of Social Services, Investigator Phillipe Miles that included a review of medical records, interview with witnesses, facility staff and medical services staff.

The investigation revealed the following:

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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20211117133315
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: 09/14/2022
NARRATIVE
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Regarding Allegation Resident sustained unexplained bruising: investigation revealed that Resident #1 sustained bruising to both wrists that was observed by the Witness (W1) during a visit to the facility on 08/21/21. A review of the facility’s Nurse’s Notes entitled, “Resident Body Check” (dated 08/21/21) documented Staff #3 evaluated the resident’s bruising and found no open wounds or skin tears nor bruises painful to the touch. In addition, S3 conducted a resident body check. S3 confirmed that the medication (Clopidogrel 75 mg Tab - commonly known as Plavix) due to resident’s history of stroke could possibly have a side effect as well. The medication works as a blood thinner by increasing the blood flow to the heart; and, it could cause bruising easily. S3 indicated that she continued to follow up with Resident #1 to see if the minor bruising worsened; but it got better. Interview with Administrator Clark confirmed that an Unusual Injury/Incident Report was not completed and submitted to CCLD.

Based on interviews and observations and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained unexplained bruising while in care is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to Administrator Peggy Clark.


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

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7