198602069-5-31-2022-11-AS-JHAD-CK7UXT-20221014155852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/19/2021
Date Signed: 05/31/2022 11:37:48 AM

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
06/09/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210609104746

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:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	11:32 AM

ALLEGATION(S):

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Facility did not ensure facility was free from pests
Staff did not meet resident's hygiene needs

INVESTIGATION FINDINGS:

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On 08/19/2021 around 02:00pm 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 in person via face to face meeting with Peggy Clark.

The Investigation consisted of the following: On 06/10/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 6/10/2021 LPA Caldron 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) and pest control records for 3 months. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8. On 6/10/2021 LPA Calderon interviewed R2 – R13. LPA Calderon could not interview R1 due to communication barriers. On LPA Calderon received and reviewed 2 videos taken from Witnesses on 6/5/2021 and 6/7/2021.

Substantiated

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: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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-20210609104746

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: 08/19/2021

NARRATIVE

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Allegation: Staff did not meet resident's hygiene needs
It is alleged Staff did not meet resident's hygiene needs. On 06/10/2021 LPA Calderon and LPM Hammond interviewed the Administrator S1, S1 stated Hospice was responsible for providing baths to the resident, but this was not being done. Administrator stated S1 reached out to Hospice to remind them of that responsibility. Staff states hospice was responsible for bathing R1. The Administrator stated the facility staff are responsible for providing bed baths to R1, but it was not being done which contributed to ants crawling on the R1 face. LPA Calderon reviewed R1 file and observed the hospice Care Plan does include bathing. LPA Calderon could not interview R1 due to communication problems. LPA Calderon interviewed R2 -R13 most but not all stated that they took their own baths and did not need staff help.

Allegation: Facility did not ensure facility was free from pests:
It is alleged that the Facility did not ensure facility was free from pests. It is alleged that R1 had ants on R1 face, mouth, ears and body while sleeping. On 6/09/2021 LPA Calderon interviewed R1 family member who stated W1 visited R1 on 6/5/2021 and noted ants on R1 face and body and then W2 visited R1 on 6/7/2021 and took video of large number of ants on R1 face. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all stated ant problems in the facility and stated ants in room 103, 105, 130, 130 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents stated ant problems in the facility. LPA Calderon could not interview R1 due to communication problems. On LPA Calderon received and reviewed 2 videos taken from W1 members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed.

Based on LPM and LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.
A 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: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210609104746

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: 08/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/27/2021 Section Cited CCR 87705(C)(3)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia :(c) Licensees who accept and retain residents with dementia..(3) In addition to...(A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;	1 2 3 4 5 6 7	Administrator to develop a training plan for staff that work with residents that have dementia and submit plan to LPA no later than 8/27/2021
	8 9 10 11 12 13 14	Based on observation, interviews facility faciled to clean R1 face after drinking cocnut water and failed to notice ants in R1 bed which poses an immediate health, safety risk to residents	8 9 10 11 12 13 14	Administrator to develop a training plan for staff to work with residents that have dementia and need to be bathe or washed and submit plan to LPA no later than 06/10/2022
Type B 06/10/2022 Section Cited CCR 85072(b)(2)	1 2 3 4 5 6 7	85072 Personal Rights:(B)The licensee shall insure that each client is accorded the following personal rights.(2)To have the facility inform his/her relatives and authorized representative....	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on observation, interviews, video, facility failed did meet resident's hygiene needs which posed an immediate health, safety risk to residents	8 9 10 11 12 13 14

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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