<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/04/2025
Date Signed: 04/04/2025 03:02:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250327140429
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:GOMEZ, VERONICAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 140DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Veronica Gomez, AdministratorTIME COMPLETED:
04:17 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adults are working in the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/04/25, Licensing Program Analyst (LPA) Mario Leon conducted an initial visit to gather information regarding the above allegation. LPA met with staff one, Veronica Gomez (S1) Administrator, and the purpose of the visit was explained. LPA was granted entry to the facility.
Investigation consisted of the following: On 04/04/25 LPA requested Resident Roster (dated 04/02/25), staff roster (dated 04/04/25), Personnel Report (LIC500 - dated 02/25/25) and LPA toured the physical plant to interview four (4) residents (R1-R4) and three (3) staff (S1-S3).
Investigation revealed the following:
Regarding the Allegation, "Uncleared adults are working in the facility.". It has been alleged that two (2) uncleared care staff have been allowed to work at the facility.

Report continues, see LIC9099-C.

Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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-20250327140429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 04/04/2025
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 03/28/25 LPA conducted record review of Facility Personnel Report Summary, which shows One-Hundred and Thirty-Two (132) staff who are currently associated to the facility. On 04/04/25, at 8:22AM, LPA compared the Facility Personnel Report Summary to the staff roster that was provided (dated 04/04/25) and observed two (2) staff (S4-S5), scheduled to work on 04/04/25, who were not listed as being associated to the facility. From 9:00AM to 09:45AM, LPA interviewed two (2) residents (R1-R2) and three (3) staff (S1-S3). R1-R2 and S1-S3 have denied the allegation has taken place. From 9:50AM - 11:20AM, LPA sat with S1 to verify S4-S5 status. One (1) staff was found as associated to the facility, with their maiden name listed, and one (1) staff remained uncleared through Care Provider Management Bureau (CPMB) and will not be allowed to work at any care facility until that staff receives clearance from CPMB. From 2:00PM to 2:45PM, LPA interviewed two additional residents (R3-R4) who have also denied the allegation has taken place.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met.
Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D.

One deficiency has been cited, see LIC9099-D.

An exit interview was held with staff one, Veronica Gomez (S1). A copy of this report, the deficiency cited, and facilities' appeal rights have been provided to Veronica Gomez (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20250327140429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2025
Section Cited
CCR
87355(a)
1
2
3
4
5
6
7
87355 Criminal Record Clearance
(a) The Department...all individuals specified in Health and Safety Code section 1569.17 and shall...deny... employment...or presence in the facility, based upon the results of such review.
1
2
3
4
5
6
7
Licensee (S1) has agreed that prior to returning to work at this care facility, the uncleared staff will have conducted a fingerprint clearance through Care Provider Management Bureau (CPMB) on, or before, the POC due date as 04/15/25.
8
9
10
11
12
13
14
This has not been met as evidenced by:
The facility has allowed one (1), uncleared, staff member to be employed at the facility.
8
9
10
11
12
13
14
S1 will inform LPA of fingerprint findings at Mario.Leon@DSS.CA.GOV
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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3