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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:35:36 PM

Substantiated


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
06/02/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20220602113632
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: DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:ASST ADMIN VERONICA GOMEZTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility has roaches.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 06/06/2022 at around 09:00 AM and was greeted by Assistant Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 06/06/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Assistant Administrator (S1). On 06/03/2022 LPA Calderon interviewed W1 for complaint. On 06/06/2022 LPA Calderon requested copies of the following: 6 months of pest control records, cleaning records for facility. On 06/06/2022 LPA Calderon received cell phone video of a roach walking in the facility. On 06/06/2022 LPA Calderon interviewed S2 – S5 for complaint and on 06/06/2022 LPA Calderon interviewed R1 – R10 for complaint.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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 3
Control Number 11-AS-20220602113632
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: 06/06/2022
NARRATIVE
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Regarding Allegation #1: Facility has roaches

On 06/03/2022 LPA Calderon interviewed W1 who states to have visited the facility 3 times in the past week and has seen roaches walking in the hallway area near the dinning room. W1 states to have taken video or roach walking and shown this to staff. W1 does not believe this is safe so near the dinning room area. W1 states no roaches inside family members room currently. On 06/06/2022 LPA Calderon received and reviewed cell phone video which shows a roach moving in a hallway area. On 06/06/2022 LPA Calderon interviewed S1 who states staff or resident family did not inform S1 of any roach issues but does state that there have been roach problems in the past. On 06/06/2022 LPA Calderon interviewed S2 – S5 all state that they have seen roaches in the common bathrooms, near the TV room, outside the building and coming out of pipes. On 06/06/2022 LPA Calderon interviewed R1 – R10 all state to have seen roaches near the dinning room area, in pipes and in some resident’s room. On 06/06/2022 LPA Calderon spoke to S1 who states to have had pest control company come over and spray, pending reports.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Facility has roaches is found to be SUBSTANTIATED.



An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Assistant Administrator (Veronica Gomez).

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

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20220602113632
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/17/2022
Section Cited
CCR
87303(A)
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87303 Maintenance and Operation (A) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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Licensee shall contact the pest control company to develop a plan to eradicate roaches in the facility. Licensee shall submit the plan to licensing by the POC date.
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Based on interviews, observations and records the licensee failed to ensure that the facility is kept free from roaches. This poses a potential health & safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3