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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/18/2021
Date Signed: 09/14/2022 11:31:31 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
06/14/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210614134751
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 116DATE:
08/18/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Peggy ClarkTIME COMPLETED:
01:03 PM
ALLEGATION(S):
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Staff did not provide timely medical assistance.
Staff did not check on the resident for several hours during the day.
Staff did not contact resident representative in a timely manner.
Resident assaulted another resident
INVESTIGATION FINDINGS:
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On 10/08/2021 around 1:00 PM 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 Peggy Clark.

The Investigation consisted of the following: On 06/21/2021 LPA Calderon interviewed witness for complaint. On 06/21/2021 LPA Calderon received and reviewed needs and service plan, physician report for R1. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint and on 07/01/2021 LPA Calderon interviewed R1-R10 for complaint. LPA Calderon and Administrator (S1) and conducted a tour of the physical plant.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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 3
Control Number 11-AS-20210614134751
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: 08/18/2021
NARRATIVE
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The investigation revealed the following:

Allegation 1: Staff did not provide timely medical assistance.
It is alleged on Staff did not provide timely medical assistance. On 06/21/2021 LPA Calderon interviewed W1 for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of R1 bed. On 06/21/2021 LPA Calderon received and reviewed needs and service plan and physician report for R1 the facility records stated no errors were made with R1 medical care and R1 did not sustain any injuries, but R1 did get a black eye when R1 head contacted the floor. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state R1 had fallen, but once they found out they took care of R1 medical needs. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, can be improved but their medical needs are taken care of. Residents state that they have no concerns with staff services and like living in the facility. LPA Calderon went to R1 room, R1 was sleeping and could not give a statement.

Allegation 2: Staff did not check on the resident for several hours during the day.
It is alleged on Staff did not check on the resident for several hours during the day. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of her bed and that it took some time for staff to become aware of R1 fall out of R1 bed. On 06/21/2021 LPA Calderon received and reviewed needs and service plan and physician report for R1 the facility records state that R1 medical needs are being taken care of by staff and that the facility does check in on resident at least 2 times per day and this is how they found out that R1 had fallen out of bed. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated R1 had fallen, but once they found out they took care of R1 medical needs and responded to the fall in a timely manner. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, and they deny any issues but, can be improved but their medical needs are taken care of. LPA Calderon went to R1 room, R1 was sleeping and could not give a statement.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210614134751
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: 08/18/2021
NARRATIVE
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Allegation 3: Staff did not contact resident representative in a timely manner.
It is alleged on Staff did not contact resident representative in a timely manner. On 06/21/2021 LPA Calderon interviewed W1 for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of R1 bed and W1 was made aware of the injury to R1 when the hospital called W1. Witness states that no one from the facility called W1 regarding the injury to R1 head. On 06/21/2021 LPA Calderon received and reviewed needs and services plan and physician report for R1 the facility records state that staff did contact resident family regarding the resident falling out of bed, state no major injuries, but R1 did get a black eye when R1 head contacted the floor. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state R1 had an fall, and they contacted the POA who is the W2 of W1 but had no obligation to advised witness that R1 had fallen. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, can be improved and staff does contact their families and make them aware of their medical status.

Allegation 4: Resident assaulted another resident
It is alleged Resident assaulted another resident. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that R2 had assaulted R1, but R1 did not call the police or report the assault to staff. On 06/21/2021 LPA Calderon received and reviewed all SIR reports associated to R1 and R2 and there is no report made regarding any assault. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state they had no knowledge of any assault and had never spoke to R1 regarding the complaint. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state they had no knowledge of any issue for R1 and had not seen the police at the building on the date of complaint.


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 telephonic exit interview was conducted with S1, and a hard copy was provided for records.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3