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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:07:18 PM

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
06/20/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230620143911
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: 135DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Peggy Clark, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained fractures while in care
Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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On 02/29/24 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Mario Leon initiated a subsequent, unannounced, complaint visit at the above-mentioned facility to deliver the findings below. LPA was met by Peggy Clark, Administrator, and the purpose of the visit was explained.
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 findings on 1 out 4 allegations.

On 06/21/23 the Departments’ Investigation Branch Investigator (IB) Jose Santana resumed investigation.
Report continues, see LIC9099C.
Substantiated
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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 6
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 02/29/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: " Resident sustained fractures while in care". It has been alleged that a resident (R1) fell while in care at the facility resulting in a broken (right) hip. IB’s interviews and record reviews revealed the following: On 02/08/2023, during R1’s admission at the facility, R1 walked without assistance and was not known to be a major fall risk. It was recommended that R1 use a walker for slightly unsteady gait and be supervised while walking. On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture due to osteoporosis and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed, despite having had a recent hip fracture and walking with a limp. S3 indicated that had R1 been reassessed, S3 also indicated that the facility would have requested “all the protective things” R1 would need. The facility moved R1 to a different memory care unit and placed R1 on Karemore Hospice on 3/16/2023. Despite these added services, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. In response, the facility staff placed pillows next to R1 and engaged the half bed rail to restrain future falls, but R1 was again not reassessed and R1’s responsible person was not notified of the falls. In addition, R1 continued ambulating without a cane and sometimes without supervision. It does not appear the facility requested safety equipment or other protective measures, aside from medication adjustment, and the facility did not provide sustained increased supervision despite claims to the contrary. Two days after R1 expressed pain following her fall on 6/03/2023, R1 sustained a minimally displaced left femoral neck fracture.
Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D.

Regarding the allegation: "Resident sustained multiple falls while in care". IB’s investigation revealed the following: On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed despite having had a recent hip fracture and walking with a limp. Due to changes in their medical condition, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. R1 continued ambulating without a cane and sometimes without supervision. The facility did not request safety equipment or implement protective measures, aside from medication adjustment. Report Continues, see LIC9099C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 02/29/2024
NARRATIVE
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Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided to Peggy Clark, Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/20/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230620143911

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: 135DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Peggy Clark, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
3
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5
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7
8
9
Resident sustained injuries while in care
INVESTIGATION FINDINGS:
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On 02/29/24 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Mario Leon initiated a subsequent, unannounced, complaint visit at the above-mentioned facility to deliver the findings below. LPA was met by Peggy Clark, Administrator, and the purpose of the visit was explained.

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 findings on 1 out 4 allegations.
On 06/21/23 the Departments’ Investigation Branch Investigator (IB) Jose Santana resumed investigation.
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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 6
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 02/29/2024
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: "Resident sustained injuries while in care". Interviews and record reviews revealed that the contusion to R1’s right eye and forehead were sustained when R1 accidentally struck their bed rail due to agitation, as caregivers attempted to change R1’s incontinence briefs. Staff stated that R1 deliberately banged their head on the walls. R1 often required up to three caregivers to change their incontinence briefs due to R1’s high combativeness. On the early morning hours of 6/02/2023, while R1 was in bed, an overnight shift staff found R1 with blood on their mouth and teeth. Staff denied R1 sustained an unwitnessed fall. It is important to note that the caregiver moved R1’s legs up and placed pillows next to their body to keep R1 from getting out of bed. It is also important to note, for level of care purposes, that R1 had previously, at times, gotten out of bed and wandered about the facility.

Based on record reviews and interviews 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.
An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided to Peggy Clark, Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
87463(c)
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Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and … if any, when there is significant change in the resident’s condition, …first, as specified in Section 87467, Resident Participation in Decision Making.
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The administrator agreed to create a plan of correction to ensure that reappraisals are conducted when significant change in the resident’s condition are observed. Proof of corrections will be submitted prior to POC due date, via email, to mario.leon@dss.ca.gov
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This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that R1 was reappraised following a change in their medical condition after hospitalization, which posed an immediate risk to the health, safety and personal rights of residents in care.
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Type B
03/01/2024
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are …

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The administrator agreed to create a plan of correction to ensure that appropriate assistance is provided to residents when observations reveal unmet needs. Proof of corrections will be submitted prior to POC due date, via email, to mario.leon@dss.ca.gov
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brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical and mental functioning, R1 was observed which posed an immediate risk to the health, safety and personal rights of 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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6