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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:41:44 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, 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
12/11/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231211093156
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: 130DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Peggy Clark, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide a comfortable environment for residents
INVESTIGATION FINDINGS:
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On 12/18/23 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark, Administrator (S1), and LPA explained the purpose of the visit. LPA toured the facility.

The investigation consisted of the following:
On 12/18/23 LPA requested and reviewed facility documents and toured the facility. LPA interviewed ten (10) out of one-hundred thirty (130) residents and six (6) out of seventy (70) staff.

The investigation revealed the following:
Regarding the allegation: "Staff did not provide a comfortable environment for residents". It has been alleged that one resident was tampering with resident's juice cups prior to the cups being served.

Report Continues, see LIC9099C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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 2
Control Number 11-AS-20231211093156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 12/18/2023
NARRATIVE
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LPA interviewed six (6) staff (S1-S6). All staff have denied the allegation. LPA interviewed ten (10) residents (R1-R10). Seven (7) out of ten (10) residents have denied the allegation.
Record reviews revealed that the subject had written a detailed note, explaining why they would not have completed the allegation listed above.

Based on record reviews, interviews and observations conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There were no deficiencies cited during today's visit.

An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2