198602069-8-10-2023-11-AS-UCOL-D2XVRH-20240301153956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/10/2023
Date Signed: 08/10/2023 05:07:54 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
06/20/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230620143911

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 126	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Veronica Gomez, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff failed to provide resident's authorized representative with incident reports

INVESTIGATION FINDINGS:

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On 08/10/23 Licensing Program Analyst (LPA) Mario Leon initiated a subsequent complaint visit for the allegations listed above to deliver findings. Today’s complaint investigation was conducted with Veronica Gomez, Administrator.

The investigation consisted of the following:

On 06/21/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit at this facility. LPA toured the facility, and requested and reviewed resident records which consisted of: Medical assessments and internal assessments, resident appraisals, needs and services plans. LPA interviewed 12 out of 123 residents. LPA also requested and reviewed communications between Reporting Party (RP) and S1, and internal communication log related to facility residents.
On 08/10/23 LPA delivered this finding.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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-20230620143911

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: 08/10/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Staff failed to provide resident's authorized representative with incident reports

During interviews, S2 informed LPA that facility had sent out R1 due to aggressive behavior. LPA observed history of incident reports from facility, none of which noted that R1 had been admitted to the hospital. Interviews with the RP have also indicated the facility had not provided any information to the RP.

Based on the interviews conducted and records review, LPA found enough evidence to support the allegation. Therefore, The “preponderance of the evidence” standard has been met and the allegation has been "substantiated".

Deficiencies have been cited and a plan of corrections has been formed with Administrator, Veronica Gomez. See LIC9099-D.

An exit interview was conducted and a copy of this report has been provided to Veronica Gomez, Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230620143911

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: 08/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/17/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report..to the licensing agency and to the person responsible..	1 2 3 4 5 6 7	Veronica Gomez and LPA have agreed upon the following: Facility will ensure there to be an in-house LIC624 CHECKLIST, which will include patient name, date, who was informed/included in the conversation. The facility will also fax LIC624 to licensing, along with a copy of the in-house LIC624.
	8 9 10 11 12 13 14	within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include..attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by lack of paper trail between reporting party and licensee.	8 9 10 11 12 13 14	The facility will have an in-staff meeting, with a time length and sign-in sheet of those who've attended, related to CCR 87211(a)(1) which shall include witnessed AND unwitnessed falls that occur in the facility as well as admittance to any outside facility, location and contact details. Updated information will be sent via email at Mario.Leon@DSS.CA.GOV
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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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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