198602069-10-5-2022-11-AS-MVAO-CNEU2K-20230125141204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:52:49 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
10/03/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20221003104346

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: 120	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Peggy Clark		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff will not allow resident to return to facility

INVESTIGATION FINDINGS:

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On 10/05/2022 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon and LPA Perry Scott 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 10/05/2022 LPA Calderon and LPA Scott interviewed (S1) and conducted a tour of the physical plant. LPA Calderon and LPA Scott obtained copies of Staff and Resident rosters, SIR reports, Physicians Report, Needs and Service Plan, hospital records, eviction notice, and the retraction of the eviction, and the admissions agreement for R1. On 10/05/2022 LPA Calderon and LPA Scott attempted to interviewed R1 regarding the complaint, but there was no answer to calls made. On 10/05/2022 LPA Calderon and LPA Scott interviewed W1 for complaint and on 10/05/2022 LPA Calderon and LPA Scott interviewed S1-S4 for complaint.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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-20221003104346

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: 10/05/2022

NARRATIVE

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Allegation 1: Staff will not allow resident to return to facility. On 10/05/2022 LPA Calderon and LPA Scott interviewed S1-S4, and they all stated the following: W1 and R1 appeared to have some type of altercation in their room and W1 asked R1 to leave. R1 appeared to consume alcohol and became aggressive with staff and W1. S1-S4 all state that there were no issues or concerns with R1’s behavior prior to the incident above. 911 was called and R1 was taken to the hospital for evaluation. It appears that S4 requested that S3 or S2 give R1 a 30-day eviction notice for aggressive behavior. Then later S4 retracted the 30-day notice of eviction. On 10/05/2022 LPA Calderon and LPA Scott interviewed W1 and W1 stated that W1 was under stress and had an altercation with R1; and asked R who stated to leave their room. Subsequently, W1 was allegedly told by S3 that R1 would no longer be allowed back into the facility. W1 then spoke to S4 who allegedly told W1 that that was a mistake and R1 would be allowed to return to the facility once he was evaluated by hospital staff. On 10/05/22 LPA Calderon and LPA Scott attempted to interview R1 about the complaint but there wasn’t an answer and the voicemail was not setup to receive messages. On 10/05/22 LPA Calderon and LPA Scott reviewed facility records for R1. LPA Calderon and LPA Scott noted a retracted 30-day notice for R1.

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) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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