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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:44:20 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
07/31/2023 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230731141841
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: 132DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Assistant Administrator Peggy ClarkTIME COMPLETED:
03:57 PM
ALLEGATION(S):
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Due to staff negligence, resident did not have blood sugar checked.
Staff are falsifying resident records.
Due to staff negligence, resident did not receive medications.
INVESTIGATION FINDINGS:
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On 05/10/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Receptionist/Caregiver and Assistant Administrator Peggy Clark and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA interviewed the Receptionist/Caregiver and Licensed Vocational Nurse and reviewed facility and resident records. On 05/09/2024 Licensing Program Analyst (LPA) Regina Cloyd and LPA Socorro Leandro conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPAs met with Administrator Veronica Gomez and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed Register of Residents, 05/09/24 Shift Schedule, requested for the facility’s Plan of Operation, and interviewed four (4) residents and nine (9) staff members which includes (4) MedTechs and (5) Caregivers. LPA Socorro Leandro interviewed eight (8) residents and two (2) staff members which includes the Administrator and one (1) caregiver.
Continue to LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 3
Control Number 11-AS-20230731141841
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: 05/10/2024
NARRATIVE
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On 08/10/23 Licensing Program Analyst (LPA) Mario Leon initiated a complaint visit for the allegations listed above. Today’s complaint investigation was greeted by, and conducted with, Veronica Gomez, Administrator. LPA explained the purpose of the visit. The investigation consisted of the following: LPA attempted contact with the reporting party (RP), who was unavailable. LPA toured the facility and interviewed three (3) clients, two (2) staff and one (1) witness. LPA requested facility records and staff records.

Allegation(s):

Due to staff negligence, resident did not receive medications.
Staff are falsifying resident records.



The investigation revealed the following: Regarding the allegation "Due to staff negligence, resident did not receive medications,” and “staff are falsifying resident records,” it is being alleged that R1 left the facility on 07/19/23 and staff notated on the EMAR that R1 took R1’s 8:00 AM and 12:00 PM medication. RP stated that during this time, R1 was away from the facility and did not receive medication. Record review reveals that R1 did not take R1’s 8:00 AM nor 12:00 PM medication on 07/19/23. The EMAR revealed that R1 only took 8:00 PM medication on 07/19/23. Interviews conducted reveal: 10 out of 12 staff members indicate that when families or residents provide notice of a facility departure, MedTech will prepare medication and leave at the front desk to ensure that residents do not miss their dose(s). Three (3) out of four (4) resident interviews, including R1, indicate that medication is provided when they need to leave the facility for a great length of time. LPA Leandro’s resident interviews reveal: 5 out of 8 residents, including four (4) from memory care, were unaware of the medication release process. Regarding the allegation “Due to staff negligence, resident did not receive medications," and “staff are falsifying resident records,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.


No deficiency was cited for these (2) allegations.

Continue to LIC9099-C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230731141841
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: 05/10/2024
NARRATIVE
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Allegation(s):

Due to staff negligence, resident did not have blood sugar checked.


The investigation revealed the following: Regarding the allegation " Due to staff negligence, resident did not have blood sugar checked,” it is being alleged that R1 did not have R1’s blood sugar tested the last two days. RP called on 07/31/23. Record review reveals that R1’s blood sugar was tested on 07/29/23 and 07/30/23. Blood sugar was not tested on 07/31/23. On 08/10/23, LPA Mario Leon interview with License Vocational Nurse (LVN) (S3/W1) indicated that R1 refused to be tested. The facility has a numbering system and S3/W1 was on number 5 and R1 had number 11. S3/W1 informed R1 that S3/W1 was unable to immediately assist R1. Then R1 refused. Based on record review and interview, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Peggy Clark.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3