198602069-4-23-2025-11-AS-RORN-DHJM5V-20250611091858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/23/2025
Date Signed: 04/23/2025 11:46:06 AM

Unsubstantiated

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
04/01/2025 and conducted by Evaluator Deborah Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250401135956

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	GOMEZ, VERONICA		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS:	DATE:	04/23/2025
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Peggy Clark		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not ensure resident's bed was working properly.
Staff did not ensure resident's electrical outlet was fixed properly.

INVESTIGATION FINDINGS:

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On April 23, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit to continue investigation and to deliver findings regarding the above allegations. LPA Lee met with Peggy Clark Administrator and explained the reason for the visit.

The investigation consisted of the following:
On April 10, 2025, LPA inspected R1’s room, reviewed and requested, staff roster (dated 4/9/25), resident's roster (dated 4/7/25), Appraisal/Need and Services Plan for R1 (dated 6/1/24), C1’s Physician's Report for Residential Care for the Elderly (RCFE) dated 1/30/25. LPA reviewed R1’s file. LPA Lee interviewed 3 residents (R2-R4), 3 staff (S1- S3) and Administrator (A1).

On April 23, 2025, LPA interviewed 1 resident (R1), and reviewed a copy of R1's body check form.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

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-20250401135956

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: 04/23/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not ensure resident’s bed was working properly.

The detail of the complaint alleges that R1’s medical bed doesn’t work and hasn’t been working for three weeks and R1 had developed back sores due to not being able adjust the bed. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator (A1) Peggy Clark who denied the allegation stating that as soon as R1 complained about her bed not working, a message went out to our maintenance guy, and he fixed the bed that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the bed was not working, it was fixed the same day. On April 10, 2025 between 2:00pm and 3:00pm, LPA Lee interviewed 3 residents and of those interviewed 3 out of 3 residents stated that problems in the facility are usually addressed right away. On April 10, 2025, LPA inspected R1’s room and observed that the bed was operational as A1 demonstrated the bed was working by moving the head and feet sections in an up and down motion with the motor control. On April 23, 2025, LPA Lee interviewed R1 who stated that the bed is working fine and says that there is no problems with the bed. R1 informed LPA that there are no issues with R1's back as there are no sores on R1’s back as reported in the complaint.

On April 23 2025, LPA obtained and reviewed a copy of R1’s body check (dated 4/19/25) which indicated no sores of any kind on R1’s back as reported in the complaint.

Based on the information gathered, there is insufficient evidence to support the stated allegation.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250401135956

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: 04/23/2025

NARRATIVE

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Allegation: Staff did not ensure resident’s electrical outlet was fixed properly.

The detail of the complaint alleges that the electrical outlet blew out has not been working for 3 weeks. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator Peggy Clark who denied the allegation stating that as soon as R1 complained about the electrical outlet by the bed not working, a message went out to our maintenance guy, and he fixed outlet that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the electrical outlet in the room was not working, it was fixed the same day. On April 10, 2025, LPA inspected R1's room and observed that the the electrical outlet was working. On April 23, LPA interviewed R1 who stated that the outlet is working.

Based on the information gathered, there is insufficient evidence to support the stated allegation.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED

No deficiencies were cited for the above allegation. Exit interview was conducted. A copy of this report was provided to Peggy Clark, Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

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