198602069-5-12-2023-11-AS-JHAD-CRVMAD-20230516092608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:33:54 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
01/24/2022 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220124171913

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: 121	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Peggy Clark		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident was sexually assaulted while in care.

INVESTIGATION FINDINGS:

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On 05/12/23 Licensing program analyst (LPA) Lizeth Villegas and Licensing program manager (LPM) Janae Hammond conduced a subsequent complaint visit to render investigation findings. During todays visit LPA and LPM met with Administrator Peggy Clark and the purpose of todays visit was explained.

The investigation consisted of the following:
On 01/26/22 Licensing Program Analyst (LPA) Jade Jordan conducted initial visit, LPA toured physical plant, conducted Health and safety checks on residents in care and obtained a copy of resident and Staff roasters.

On 1/25/22 the complaint investigation was referred to the department of social services investigation bureau and assigned to investigator Robert Kujawa and was accepted for an assignment. IB investigator conducted interviews with resident #1 (R1) and administrator Peggy Clark (staff #1(S1) ).

On 5/12/23 LPA and LPM conduced interviews with staff #2-6 and conducted interviews with residents #2-11.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20220124171913

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: 05/12/2023

NARRATIVE

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LPA and LPM attained copy of R1’s file (Emergency I.D. sheet, admission agreement, physicians report, DNR letter, consent forms, pre-placement appraisal, needs and service plan, medication list and nurse notes) and obtain a copy of staff and resident rosters.

The investigation revealed the following:

Allegation: Resident was sexually assaulted while in care. It is being alleged that R1 was sexually assaulted at the facility by an unknown perpetrator. On 02/09/22 Robert Kujawa interviewed administrator (S1) Peggy Clark about the allegations above, S1 denied allegations and reported she was unaware of any resident being sexually assaulted. On 3/30/2022 Robert Kujawa interviewed R1 regarding the allegations above, during the interview R1 denied being sexually assaulted while in care at the facility.

On 05/12/23 LPA and LPM interviewed Staff # 2-6, 5 out of 5 staff denied allegation.

On 05/12/23 LPA and LPM interviewed residents #2-11, 10 out of 10 residents denied allegations.

On 05/12/23 LPA and LPM conducted a review of R1 file, during the review LPA and LPM did not observe any documents to support the allegation. Based on interviews conducted and records reviewed there is insufficient evidence to support allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted to Administrator Peggy Clark and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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