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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:08:01 PM

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
09/30/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20220930144632
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: 119DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:ADMINISTRATOR VERONICA GOMEZTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff allowed resident to wander from facility resulting in a fracture
Staff abandoned resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Palmcrest Grand Residence on 10/03/2022 and 07/10/2023 and was greeted by Administrator Peggy Clark (A1). LPA Calderon spoke to A1 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.
During this investigation, LPA Calderon interviewed A2 (Clark), R1-R14, S1-S4, A1 (Gomez). This interview was conducted on 10/03/2022, 02/08/2023, 07/10/2023, 08/17/2023 and 08/23/2023. On 02/23/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, needs and service plan (06/27/2022), physician report (12/21/2021), College Medical Center hospital records (09/13/2022), medical administration record (10/20/2022), Home Health Care records (10/19/2022) for R1. On 11/23/2022 received Department of Social Service Investigation Branch (IB) report.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
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 4
Control Number 11-AS-20220930144632
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: 08/24/2023
NARRATIVE
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Regarding Allegation #1: Staff allowed resident to wander from facility resulting in a fracture.

This complaint alleges resident R1 left the facility memory care unit and sustained an injury in the facility parking lot. On 11/23/2022 received and reviewed the department’s Investigation Branch (IB) Investigator Edward Hector report. The investigators report states: During the investigation I obtained and reviewed medical records. I interviewed the R1, R1 son and facility administrator and facility staff. All information and interviews confirm that R1 was assigned to secure and locked memory care unit. R1 absconded from the memory care unit and was later found outside in the parking lot of nearby facility with an ankle injury. R1 did not explain how R1 escaped the memory unit and staff have no information on how R1 got out without any alarms going off. There is sufficient evidence to support the allegation of lack of supervision”.

Regarding Allegation #2: Staff abandoned resident.

This complaint alleges that the facility refused to allow R1 to return to the facility after a hospital visit. On 08/23/2023 LPA Calderon interviewed A1 Veronica Gomez and A2 Peggy Clark. A1 and A2 expressed that A1 went to the hospital to evaluate R1. A1 and A2 expressed that R1 had been very aggressive with staff and other residents striking staff and residents. A1 and A2 expressed that A1 evaluated R1 and R1 was very aggressive at the hospital. A1 and A2 expressed that due to R1 being very aggressive with staff R1 was not allowed to return to the facility. On 08/17/2023 LPA Calderon interviewed A1(Gomez) for complaint. A1 (Gomez) expressed that R1 was taken to the hospital for R1 left ankle injury after leaving the memory care unit and being found in the facility parking lot. A1 (Gomez) expressed that A1 went to the hospital to evaluate. A1 (Gomez) expressed that R1 was combative with A1, urinated on the floor and needed more care than the facility could provide. A1 (Gomez) expressed that R1 was moved to Saint Edna’s in the city of Santa Ana for further care and never returned to the facility. A1 (Gomez) expressed that the facility would never abandon a resident in the hospital without evaluating a resident for additional medical care and informing R1 family. On 07/10/2023 LPA Calderon interviewed S1-S4 for complaint. S1-S4 expressed that R1 was found in the facility parking lot with a left ankle injury. S1-S4 expressed that it is normal for staff to evaluate a resident that is taken to the hospital for further care prior to the resident being returned to the facility. S1-S4 expressed that they have no knowledge as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20220930144632
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: 08/24/2023
NARRATIVE
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Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) “staff allowed resident to wander from facility resulting in a fracture” “staff abandoned resident” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220930144632
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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation....(2) Safety measures to address behaviors such as wandering, aggressive behavior ....This requirement is not met as evidenced by:
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Administrator Veronica Gomez will develope a security plan to prevent residents of the memory care unit from absconding from the facility without staff or family with the resident.
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Based on interview, observation, and record review, the licensee failed to ensure that the facility prevented the resident from absconging from the memory care unit and being found in the facility parking lot which poses a health risk to residents in care.
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Type B
09/01/2023
Section Cited
CCR
87224(d)
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87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by:
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Administrator Veronica Gomez will provide additional training to management staff regarding proper eviction notice to residents in care or residents family members.
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Based on interview, observation, and record review, the licensee failed to ensure the resident was given proper eviction notice prior to resident not being allowed to return from the hospital which pose a health and 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4