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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/23/2025
Date Signed: 04/23/2025 03:33:22 PM

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
04/16/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250416115244
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: 143DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:ADMINISTRATOR PEGGY CLARKTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not providing adequate care and supervision of a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/23/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Palmcrest Grand Residence Facility and was greeted by Administrator Peggy Clark (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Administrator S1, Staff S2-S3, resident R1-R14. LPA Calderon obtained the following records: physician report (dated 01/13/2025), Preplacement plan (dated 02/04/2025), incident report (dated 04/13/2025, 04/14/2025 and 04/18/2025), Kaiser Hospital records (dated 04/13/2025 to 04/18/2025) for R1.

The investigation revealed the following:

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
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)
Page: 1 of 2
Control Number 11-AS-20250416115244
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
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
Regarding the Allegation: Staff is not providing adequate care and supervision of a resident while in care.

This complaint alleged that staff did not supervise R1 who had 3 witnessed falls. Toured the facility with S1, LPA Calderon did not notice any negative interactions between staff and residents. Records review indicate the following: Physician report indicate health issues and is ambulatory, Preplacement plan indicates that R1 has unsteady gait. Incident reports indicate R1 had 3 witnessed falls on 04/13/2025, 04/14/2025 and 04/18/2025. Incident report indicates that all falls happened in the night shift. Hospital records indicate minor injuries and R1 was returned to the facility. Interviews indicate the following: 4 out of 4 staff deny the allegation. R1 could not answer any questions due to health issues. 13 out of 14 residents deny the allegation.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff is not providing adequate care and supervision of a resident while in care” is found to be UNSUBSTANTIATED.


No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Peggy Clark (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
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 2