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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:15:21 AM

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
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:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:ADMINISTRATOR VERONICA GOMEZTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff allowed resident to wander from facility resulting in a fracture
INVESTIGATION FINDINGS:
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13
THIS REPORT SUPERSEDES THE REPORT DATED 08/24/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
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) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 5
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 01/18/2024
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 the 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”.

Based on LPA’s observations and interviews conducted along with records reviewed, there is sufficient evidence that facility “Staff allowed resident to wander from the facility resulting in a fracture”, therefore this allegation is determined to be “substantiated”.



An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 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: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
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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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) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
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:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:ADMINISTRATOR VERONICA GOMEZTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff abandoned resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 08/24/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS HAVE CHANGED: UNSUBSTANTIATED
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:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 01/18/2024
NARRATIVE
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Regarding Allegation #1: Staff abandoned resident.

This complaint alleges that the facility refused to allow R1 to return to the facility after a hospital visit.

On 08/17/2023 LPA Calderon interviewed A1(Gomez) for a complaint. A1 (Gomez) expressed that R1 was admitted to the hospital for a left ankle injury sustained during the incident when (R1) wandered off the facility.


On 08/23/2023 LPA Calderon interviewed A1 Veronica Gomez and A2 Peggy Clark. A1 claimed that the facility would never abandon a resident in the hospital without evaluating a resident for additional medical care and would take steps to notify the family representatives of R1. A1 and A2 expressed that A1 went to the hospital to evaluate R1. A1 and A2 claimed that R1 had been physically violent with staff and residents while at the facility and continued with violent behavior towards A1 and A2 while at the hospital. Evaluation of (R1) revealed due to (R1’s) violent behaviors, the hospital records confirmed: “Psychiatric based hospitalization is necessary due to patient confusion and easily agitation and disorientation”. Medical records revealed that based on medical assessment, it is recommended to transfer (R1) to a psychiatric unit when medically cleared. Records indicated that medical professionals consulted with family representatives and agreed that (R1) should go to a psychiatric facility to receive treatment before returning to the facility. S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know 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 the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”.
S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know 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 the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”.
Based on LPA’s observations and interviews conducted along with records reviewed, there is insufficient evidence that facility “Staff abandoned resident”, therefore this allegation is determined to be “unsubstantiated”.
An exit interview was conducted, and a copy of the Complaint Report to the Administrator Peggy Clark (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5