198602069-3-19-2024-11-AS-MLEN-D3HUSX-20240319155104

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:51:14 PM

Document Has Been Signed on 03/19/2024 03:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	5625954551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 131	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Veronica Gomez, Administrator		TIME COMPLETED:	04:23 PM

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On 03/19/23, Licensing Program Analysts (LPA) Mario Leon, Regina Cloyd and Troy Watson, along with licensing program manager (LPM) Ulysses Coronel, conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs and LPM met with the Administrator Peggy Clark and assistant administrator Veronica Gomez and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10 residents.

The facility is a large, two-story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units.

LPAs and LPM conducted record reviews of six (6) resident records and six (6) staff records. The facility disaster drill and fire drill were conducted during the day and night shifts on 02/13/24 and 02/15/24. The facilitys' disaster plan is current and in compliance with Title 22 regulations at the time of visit.

LPAs and LPM checked resident units. Mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting in the restroom, and sufficient toiletries are accessible to residents.

Report continues, see LIC809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/19/2024

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The water temperature properly measured between 105-120 degrees F and the internal air temperature was comfortable, measured at 75 degrees F.

Perishable and non-perishable food supply was checked and LPAs and LPM observed food to be fully-stocked at the time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged as of 02/20/24, toxins and knifes were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Exits/Walkways around the facility were free of debris and hazards.

LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area.

During today’s visit, there were three (3) technical assistance notes and two (2) technical violations provided; see: LIC9102AN and LIC9102TV.

There were no deficiencies cited during today's visit.

An exit interview was held with Peggy Clark and Veronica Gomez, Administrators, and a copy of this report and LIC9102AN's / LIC9102TV's were provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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