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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 11/07/2022
Date Signed: 11/07/2022 12:11:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
05/02/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220502121502
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: 77DATE:
11/07/2022
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Peggy Clark TIME COMPLETED:
12:01 PM
ALLEGATION(S):
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Residents sustained severe injuries while in care.
Staff mishandled resident multiple times.
Staff did not respond to call button in a timely manner.
INVESTIGATION FINDINGS:
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On 11/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by Administrator Peggy Clark staff #1 (S1). LPA explained the purpose of this visit is to deliver the findings on the allegations mentioned above.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ernand Dabuet conducted visits 05/03/22, 09/16/22, 09/27/22 and 11/07/22. LPA initiated an investigation for the above-mentioned allegations and interviewed with Assistant Administrator (S1). LPA requested copies of the following: staff and resident rosters, SIR reports, physician’s report, appraisal/needs and services plan, and all medical records including any hospital records for Resident #1. Department of Social Services investigator Phillipe Ryan Miles conducted a separate investigation that included a review of medical records and interviews with witnesses, facility staff, and medical services personnel.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
05/02/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220502121502

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: 77DATE:
11/07/2022
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Peggy Clark TIME COMPLETED:
12:01 PM
ALLEGATION(S):
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9
Staff are mismanaging residents' medication.
Staff insults residents.
Staff did not prevent resident from engaging in inappropriate interactions with other residents.
Staff left residents in soiled clothing for extended period of time.
Staff are reusing soiled mattress pads.
Resident's bathtub is dirty.
Facility laundry pipes are in disrepair.
INVESTIGATION FINDINGS:
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On 11/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by Administrator Peggy Clark staff #1 (S1). LPA explained the purpose of this visit is to deliver the findings on the allegations mentioned above.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ernand Dabuet conducted visits 05/03/22, 09/16/22, 09/27/22 and 11/07/22. LPA initiated an investigation for the above-mentioned allegations and interviewed with Administrator (S1). LPA requested copies of the following: staff and resident rosters, SIR reports, physician’s report, appraisal/needs and services plan, and all medical records including any hospital records for Resident #1. Interviews with staff #2-#10 (S2-S10), resident #1-10 (R1-R10), and witness #1 (W1).

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20220502121502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 11/07/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident’s bathtub is dirty. It is alleged the bathtub in resident #1 (R1) is dirty. The complainant retracted her statement that the bathtub for (R1) is not dirty. The complainant was referring to other residents in the community. However, the complainant failed to provide the names, dates, or room numbers of these residents. The Department inspected (R1’s) bathroom was found to be within Title 22 regulations and was clean and operational. Interviews with residents #2 - #10 (R2-R10) and staff #1 - #10 (S1-S10) were all unable to corroborate this allegation. (S1-S10) claimed (R1) requires the housekeeping staff to provide limited services as very protected personal property and space. Based on the information collected, there is no evidence to support the allegation mentioned above.

Allegation: Facility laundry pipes are in disrepair. The complainant claimed that the pipes are not working and breaking down and leaking. The complainant was unable to provide additional detailed information. The complainant stated it happened sometime in November 2021. Interviews with residents #2 - #10 (R2-R10) and staff #1 - #10 (S1-S10) were all unable to validate this allegation. (S2) assistant administrator who oversees maintenance coordination did not have any service requests for pipes in deplorable condition. Based on the information collected, there is no evidence to support the allegation mentioned above.

Allegation: Staff are mismanaging residents’ medication. The complainant reported that (R1) is not getting medication on time as well as other residents. The complainant stated that the staff is not responsive when it comes to medication refills. The Department interviewed resident #1 (R1) who stated that he is independent and is responsible for taking his meds. (R1) the med-techs will assist in the coordination of prepping his medications and refills. As for (R1), the few times he had issues with his medications being delayed were due to the pharmacy or to his primary physician failing to authorize refills in a timely manner. (R1) claims he has never had any issues with the facility for his medications not being issued on time. Interviews with (R2-R10) all claimed that they are independent and that medications are handled properly and timely. According to Med-Tech staff #9 (S9), most residents including (R1) can take their own medications. It is the med-tech's responsibility to coordinate residents' schedules and prepare medications. The med-techs will contact the pharmacy or/primary physicians for refill authorization. (S9) denies having any issues with (R1’s) medications not being disbursed timely. The Department reviewed the Medication Administration Records for (R1) and did not find any discrepancies. Based on the information collected, there is no evidence to corroborate the allegation mentioned above.


Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20220502121502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 11/07/2022
NARRATIVE
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Allegation: Staff insults residents.
Staff did not prevent resident from engaging in inappropriate interactions with other residents.
This facility was alleged to have had a few staff who insulted residents. The complainant did not have the names of the parties involved. The complainant did not witness any of these incidents, only hearsay from the community residents. Interviews with residents #1 - #10 (R1-R10) and staff #1 - #10 (S1-S10) were all not to verify this allegation. (R1-R10) only had complimentary kind words regarding the staff. (S1-S10) reported that they all have taken training on Resident’s Rights and that there is zero tolerance for such behavior.

The complainant claimed there have been several incidents involving residents having inappropriate interactions. The complainant was not able to give further information on this alleged allegation. The complainant did not have the names of the residents and stated she did not witness any of the incidents. The complainant did not witness any of these incidents, only hearsay from the community residents. Interviews with residents #1 - #10 (R1-R10) and staff #1 - #10 (S1-S10) were all of them unable to confirm this allegation. (S1-S10) reported the staff are trained professionals and are mandated reporters and have a duty to be involved. Based on the information gathered, there is no evidence to support the allegations mentioned above.

Allegation: Staff left residents in soiled clothing for extended period of time.


Staff are reusing soiled mattress pads.
The complainant stated she is being an advocate for the residents in this community. There is a shortage of diapers and residents are not getting changed regularly. The complainant states soiled mattress pads are reused.

The complainant could not provide further details or did not know the name of the resident or the residents involved. Interviews with staff #1 - #10 (S1-S10) all dispute this claim and claimed they have not observed any residents left in soiled clothing or bed pads for an extended period. Housekeeping changes bed sheets and mattress pads. The caregivers will assist when housekeeping is not available. The housekeepers clean all rooms daily and will do a once a week deep cleaning. A new set of sheets is changed twice a week or as needed, including the pads. Interviews with residents #1-#10 (R1-R10) were unable to validate these allegations. (R1-R10) states there’s no evidence of disregarded care from the facility. Based on the information gathered, there is no evidence to support the allegations mentioned above.
Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20220502121502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 11/07/2022
NARRATIVE
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Based on information gathered, an inspection of the facility, observation, analysis of (R-1)'s service records and other resources associated with this complaint, and interviews conducted, the Department found no evidence to support the allegations listed on this complaint report.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies cited on this visit.

An exit interview was conducted with Peggy Clark and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20220502121502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 11/07/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident sustained severe injuries while in care.


Staff mishandled resident multiple times.
Staff did not respond to call button in a timely manner.

Resident #1 (R1) was admitted to this facility on 11/08/19. According to resident #1 (R1’s) Physicians Report, (R1) is an independent adult who was diagnosed on (03/25/22) with hypertension, depression, anxiety, and bipolar disorder.

On 11/30/21, (R1) was admitted to Memorial Care Long Beach Medical Center from a fall. During evaluation (R1) disclosed losing balance and falling backward, and landing on the left hand, buttock and back. Medical records indicated no trauma, no fainting or presyncope only pain to the left hand due to the fall. (R1) was diagnosed with an injury of dislocation of the Interphalangeal Joint left middle finger with a suspected fracture.

On 05/17/22, IB Investigator interviewed (R1) who self-proclaimed to being independent and does not need any assistance with any activities of daily living (ADLs), or supervision by the caregivers or staff. On the day of the alleged incident (R1) stated was applying eyedrops in the bathroom and lost balance when tilting the head back and “accidentally” fell backward. While falling rearwards, (R1) landed on the left hand. (R1) managed to dislocate the middle finger and fractured the wrist. (R1’s) wife (W1) was present in the room and yelled for help. (W1) reported no response from the staff. (W1) claimed she pushed the “call button” in their room but got no staff to respond to the call. (W1) reported staff #2 (S2) assistant administrator arrived 10 minutes after the (W1) called for help with the use of the “call button” in the room. (R1) who contacted 911 and Emergency Medical Services arrived within 15 minutes. The Department inspected (R1's) call button on 09/27/22 and tested the equipment. The call button was working properly and the front desk responded within 60 seconds.

On 05/17/22 IB Investigator received statements from (S2) who recalled on the day of the alleged incident, (R1) was in “fuzzy boots” footwear that were no fitted completely, and that the room had plenty of floor mats that “may have caused” the fall. (S2) assessed (R1’s) finger along with staff #3 (S3) med-tech who dispatched 911.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20220502121502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 11/07/2022
NARRATIVE
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(S2-S3)) did not witness the fall. According to (S3) (W1) was in a panic and called through the in-house intercom, to which (S3) claims she responded accordingly to the call. (S3) observed (R1) sitting in a chair and asked (R1) what happened. (R1) responded, “I accidentally slipped.” (S3) called 911 immediately after observing (R1’s) condition.

IB Investigator reviewed the Nurse's Notes and Call Light Log for (R1) on 06/03/22 and found (R1) "fell in the bathroom" on 11/03/22 with a fractured finger.” The Call Light Log indicated room #280 called for assistance at 3 pm and staff (S3) responded at 3:15 pm.

(R1) stated that since the fall, “there has been no change or increased level of care and supervision. (R1) continues to self-care independently without need of any type of supervision. (R1) admitted this was an accident causing injuries to the finger and “suspected” fracture of the wrist. Evidence of an incident report, nurses' notes, and logs along with interviews that staff handled the situation and responded timely for a non-life-threatening of injuries.

The Department finds no evidence to support the allegations mentioned after observing, interviewing, reviewing, and analyzing the records.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.



No deficiencies were cited during this visit.

An exit interview conducted with Peggy Clark, and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7