198602069-10-13-2022-11-AS-JHAD-CK7UQK-20221014154716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 09/13/2022
Date Signed: 10/13/2022 10:35:27 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
09/09/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220909181135

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 119	DATE:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility financially abused resident.

INVESTIGATION FINDINGS:

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On 09/13/2022 around 09:00 AM 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 (S1).

The Investigation consisted of the following: On 09/13/2022 LPA Calderon interviewed (S1) and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, property moved out form, P&I receipt, PNI account records, CRC incident report and LIC624 for W1. On 09/13/2022 LPA Calderon attempted to interviewed W1 regarding complaint, but due to W1 being held in VA hospital no interview was done. On 09/13/2022 LPA Calderon interviewed S1 for complaint. On 09/13/2022 LPA Calderon interviewed W2-W5 for complaint.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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-20220909181135

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: 09/13/2022

NARRATIVE

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Allegation 1: Facility financially abused resident. On 09/13/2022 LPA Calderon attempted to interviewed W1, but due to W1 being held in VA Hospital for 5150 hold no interview could be obtained. On 09/12/2022 LPA Calderon interviewed S1who states that W1 was found inside his room on 04/29/2022 passed out and was transported to the hospital for evaluation. S1 states that on 06/08/2022 the hospital was going to discharge W1, S1 states that S1 informed the hospital that facility could no longer care for W1 and the hospital called Assisted Living Waiver program (ALW) who then contacted W2 with Placement specialist. S1 states that they boxed up W1 personal items and cashed out W1 for 3 months of P&I which totaled $462.00 dollars on 06/08/2022. On 09/13/2022 LPA Calderon interviewed W2 who states that W2 picked up W1 personal items and $462.00 cash on 06/08/2022 and drove to the new facility and gave W3 the personal items and cash for W1. W2 states that no receipt was given. On 09/13/2022 LPA Calderon interviewed W3 who states that they did receive personal items for W1 and $462.00 cash for W1 P&I account. W3 states that the facility can account for all monies received on 06/08/2022. On 09/13/2022 LPA Calderon interviewed W4-W5 who had no knowledge of the missing P&I money. On 09/13/2022 LPA Calderon received and reviewed a receipt for $462.00 for 3 months of P&I monies which was signed and a copy of W2 driver license was noted. Received and reviewed P&I ledger for W1 for 2021 and 2022, LPA Calderon noted 3 months that was owed to W1 totaling $462.00 dollars. Received and reviewed CRC incident report dated 06/08/2022 for W1 moving W1 to new facility.

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.

A exit interview was conducted with Administrator S1, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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