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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/23/2024
Date Signed: 04/23/2024 05:10:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240417165425
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: 132DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Peggy Clark, AdministratorTIME COMPLETED:
05:19 PM
ALLEGATION(S):
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Staff yells at residents.
INVESTIGATION FINDINGS:
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On 04/23/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark, Administrator (S2), and the purpose of the visit was explained. LPA toured the facility.

The investigation consisted of the following:
On 04/23/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of one-hundred thirty-two (132) residents (R1-R3) and eight (8) out of seventy-two (72) staff (S1-S8).

The investigation revealed the following:
Regarding the allegation: "Staff yells at residents.". It has been alleged that one staff member (S1) is often yelling at residents in care.

Report continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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-20240417165425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 04/23/2024
NARRATIVE
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Between 09:00AM and 10:30AM, on 04/23/24, LPA observed multiple calls from one of the subjects (R1) in the complaint provided by the plaintiff.

Interviews revealed that two (2) out of eight (8) staff disagreed with the allegation, while four (4) out of 8 staff agreed with the allegation. 2 staff were unsure, but would believe that the mentioned staff (S1) would cause fellow staff to become displeased at completing their tasks.

Record reviews revealed that the mentioned staff (S1) has visited R1's room on 04/08/24 and 04/13/24.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was conducted with Peggy Clark, Administrator, and a copy of facilities’ appeal rights and this report have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20240417165425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
87468.1
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87468.1 Personal Rights...in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of... personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator (S2) and LPA have agreed that the licensee will make arrangements to conduct further training(s) with S1. Licensee will provide adequate further training with S1, via email, to LPA at Mario.Leon@dss.ca.gov
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This has not been met as evidenced by: Licensee did not provide R1 with dignity in their personal relationships with staff; as through interviews, S1 has been named and confirmed through six (6) out of eleven (11) total interviews
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3