198602069-8-21-2023-11-AS-JHAD-CVFPXP-20230907114241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/17/2023
Date Signed: 08/21/2023 09:28:44 AM

Substantiated

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
07/25/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20230725113010

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: 126	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Veronica Gomez		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing resident's records to authorized representative.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/17/23 Licensing program analyst (LPA) Lizeth Villegas and licesning program manager (LPM) Janae Hammond conducted a subsequent complaint visit to render investigation finding. LPA and LPM met with Administrator Veronica Gomez as the purpose of today’s visit was explained.

The investigation consisted of the following: On 8/2/23 LPA interviewed Administrator (A1) and Staff #1(S1). LPA asked for proof that requested documents were sent to resident #1 (R1) authorized representative.

The investigation revealed the following: It is alleged resident #1 authorized representative sent a reocrds request to Palmcrest Grand Residence on 6/23/23. LPA Villegas interviewed Administrator
Veronica Gomez regarding the allegation, Administrator confirmed that a request was received on 6/29/23 with a request for R1's records. Administrator reported that she gave the licensee the subpoena for records for consultant to review.
LPA interviewed staff #1 who was unaware of the allegation above.

Substantiated

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: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20230725113010

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: 08/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 8/17/23 the administrator provided emails in correspondence between facility consultant and legal services dated 08/2/23. A review of emails and information received indicate the facility did not provided R1's authorized representative with the requested documents as required by title 22 regulations.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Veronica Gomez, appeal rights explained 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: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230725113010

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/24/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	Resident records ...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. this requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator shall provide R1's authorized reporesentative with copies of R1's file by POC due date.
	8 9 10 11 12 13 14	based on records review and interviews conducted, the licensee did not provide R1's record to authorized representatvie upon request. This poses a personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3