198602069-12-17-2021-11-AS-JHAD-CK7UXU-20221014155852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 06/10/2021
Date Signed: 12/17/2021 02:04:26 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
06/09/2021 and conducted by Evaluator Jose Calderon

PUBLIC

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: 114	DATE:	06/10/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR LESLY FIGUEROA		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not ensure facility was free from pests
Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 06/10/2021 around 3pm Licensing Program Manger Janae Hammond and Licensing Program Analyst (LPA) Jose Calderon, LPA Jones, LPA Cifuentes, LPA Coronel and long-term ombudsman Medrano 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 with Administrator Lesly Figueroa.

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 6/09/2021 LPA Calderon interviewed reporting party (R1) who confirmed she visited her mother R1 on 6/5/2021 and noted ants on R1 face and body and then granddaughter 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 confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 133 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. shows ants on R1 who was sleeping in the bed

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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

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 6

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: 06/10/2021

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

On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which

The investigation revealed the following:

Allegation: Facility did not ensure facility was free from pests.
It is alleged on facility did not ensure facility was free from pests. LPA Calderon received a video of R1 with ants crawling all over R1’s face, ears, mouth, nose and bed. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 133 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed

Allegation: Personal Rights:
It is alleged that the facility violated the Personal Rights of R1. It is alleged that R1 had ants on her face, mouth, ears and body while sleeping. On 6/09/2021 LPA Calderon interviewed R1 family member who confirmed she visited R1 on 6/5/2021 and noted ants on R1 face and body and then granddaughter 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 confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 130 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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: 06/10/2021

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

Based on LPAs 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 LIC9099D.

A exit interview was conducted with Administrator Morris Stricher, 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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Citations on this Visit Report are Under Appeal!

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: 06/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 06/15/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	TAdministrator will contac pest control for the best options to treat the facility and will provid a outline of a POA by the due date.ining of staff and updated DSS no later than 06/15/2021
	8 9 10 11 12 13 14	Based on observation, interviews facility faciled to control ant problems and LPA Calderon witness ant problems in room 103 which poses an immediate health, safety	8 9 10 11 12 13 14
Under Appeal Type A 06/11/2021 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	87468 Personal Rights:(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities,..(1) "Privately operated facility" means a residential care facility for the elderly that is licensed to an individual, firm, partnership. his requirement is not met as evidenced by:	1 2 3 4 5 6 7	Adminsitrator will confirm all staff training in personal rights in residents in care. Adminstrator will provide proof and training and sign in sheet for all staff by POC due date of 6/11/2021
	8 9 10 11 12 13 14	Based on observation, interviews and video it is confirmed that there were ants on R1 face and body and ant issues for the total facility which poses an immediate health, safety	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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6