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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 03:29:27 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
12/20/2023 and conducted by Evaluator Socorro Leandro
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231220160256
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:
08:00 AM
MET WITH:Administrator - Peggy ClarkTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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On 05/10/2024 Licensing Program Analyst (LPA) Leandro conducted an unannounced, continuation complaint visit to the above-mentioned facility. LPA was met by Peggy Clark, Administrator.

Investigation consisted of the following:
On 12/22/2023 LPA Leon interviewed 6 out of 130 residents and 9 out of 70 staff.
On 05/10/2024 LPA Leandro interviewed 6 out of 132 residents and 2 out of 66 staff.
On 12/22/2023 and 05/10/2024 LPAs requested several facility records.

A total of 12 out of 132 residents were interviewed and a total of 11 out of 66 staff were interviewed.
Record review consisted of: Personnel Report, Facility Census, Unusual Incident/Injury Reports, Facility Staff Trainings, Resident 1’s (R1) Records, etc.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
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 2
Control Number 11-AS-20231220160256
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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The investigation revealed the following: Regarding the allegation “Facility staff handled resident in a rough manner” it is being alleged that facility staff blocked R1’s doorway and because of this R1 fell. 9 out of 12 resident interviews indicated that facility has not treated them in a rough manner. 9 out of 11 staff interviews indicated that they have not seen and/or heard complaints about staff handling residents in a rough manner. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was left with Peggy Clark, Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
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 2