198602069-11-13-2023-11-AS-EMAZ-CYA2EH-20231206161957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 02/08/2023
Date Signed: 11/13/2023 09:48:15 AM

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
01/23/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230123131509

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: 117	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	ADMINISTRATOR PEGGY CLARK		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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THIS REPORT SUPERSEDES THE REPORT DATED 02/08/2023 FOR CLARIFYING THE CIRCMSTANCES FOR ALLEGATION. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED
On 02/08/2023 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation for Palmcrest Grand Residence to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Veronica Gomez (A1). LPA Jose Calderon explained the purpose of the visit is to investigate the allegation mentioned above.
Investigation consisted of: LPA Calderon interviewed Veronica Gomez A1, S2-S5, R1-R13 and W1. These interviews were conducted on 02/02/2023, 02/08/2023 and 03/27/2023. LPA Calderon obtained and reviewed copies of: Physicians Report (dated 10/14/2021), Needs and Service Plan (dated 08/08/2021), Memorial Care hospital records (dated 01/20/2023), resident appraisal (dated 01/20/2023) for R1.

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: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20230123131509

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: 02/08/2023

NARRATIVE

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Allegation #1: Resident sustained an unexplained injury while in care.

This complaint alleged R1 had unexplained blood in R1 diaper. LPA Calderon conducted an interview with A1. A1 expressed that R1 did not have any unexplained injuries while in care and that on the incident date R1 had a UTI and was transported to Memorial Care Hospital for evaluation (dated 01/20/2023). Memorial Care Hospital evaluation noted that R1 had some dry blood in R1 diaper, but R1 was discharged on 01/20/2023 with new medication for R1 UTI. LPA Calderon conducted an interview with S1-S4. 4 out of 4 staff expressed that staff witnessed R1 rubbing and scratching R1 private parts and face area. 4 out of 4 staff state that R1 did not have any unexplained injuries while in care. LPA Calderon attempted to interview R1. R1 was unable to communicate due to impairments. LPA Calderon conducted an interview with R2-R13. 12 out of 13 residents expressed themselves to have no issues with staff or services provided. 12 out of 13 residents’ states that R2-R13 did not have any unexplained injuries or falls while living in the facility. 12 out of 13 residents expressed to be happy with all services provided by staff and the facility. LPA Calderon conducted an interview with W1 who has Power of Attorney for R1 medical care. W1 expressed that R1 has health issues and is not capable of giving any interview to LPA Calderon. W1 expressed that W1 was aware of R1 scratching and that staff had to cut R1 fingernails to prevent R1 from scratching R1 body. W1 expressed that W1 is aware of R1 being taken to the hospital due to UTI and appeared to be caused by R1 scratching R1 private parts. On 02/02/2023 LPA Calderon reviewed needs and service plan (dated 08/08/2021), physician report (dated 10/14/2021) which state that R1 has health issues. On 02/02/2023 LPA Calderon reviewed resident appraisal (dated 1/20/23) noted private part bleeding, health issues. R1 has health issues and is known to scratch causing some blood to be present. R1 was transported Memorial Care Long Beach hospital for UTI on 1/20/23 and returned to the facility on 1/21/23 with chief complaint “private part bleeding, prognosis scratch in the private part area.

Although the allegation “resident sustained an unexplained injury while in care” 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.

An exit interview was conducted with Administrator Veronica Gomez (A1), 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: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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