198602069-5-23-2024-11-AS-UCOL-D5SPP2-20240531112849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:04:48 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
09/06/2023 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230906092249

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 132	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	08:07 AM
MET WITH:	Assistant Administrator Peggy Clark		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not get timely medical care for resident resulting in resident's death.

INVESTIGATION FINDINGS:

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On 05/23/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with the Assistant Administrator Peggy Clark and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed the hospice plan of care summary and interviewed one (1) witness and one (1) caregiver. 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 Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230906092249

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: 05/23/2024

NARRATIVE

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On 09/07/2023, Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint investigation to address the allegation listed above. LPA Leon met with Peggy Clark, Administrator (S1), and explained the purpose of this visit. The investigation consisted of the following: LPA Leon toured the facility, and interviewed three (3) staff (S1-S3). LPA Leon requested and reviewed facility documents.

Allegation(s):

Staff did not get timely medical care for resident resulting in resident's death.

The investigation revealed the following: Regarding the allegation “Staff did not get timely medical care for resident resulting in resident's death,” it is being alleged that Resident #1 (R1) complained of chest pain at 11:30 AM, R1 was assessed by the MedTech, R1 complained of continued pain and fear at 12:30 PM, and R1 passed away at 4:35 PM. Death Report reveals that a Caregiver contacted MedTech, MedTech took R1’s vitals, called hospice, and hospice said they could come out in about 4.5 hours. Hospice Communication log reveals that the hospice company received a call on 09/01/23 11:18 AM concerning R1’s symptoms and hospice provided instruction to the facility. Interview with the hospice representative, Witness #1 (W1), indicated that staff was instructed to supply R1 with oxygen. W1 indicated that staff verbally confirmed that oxygen was administered. Interview with staff indicated that oxygen was administered to R1 and the facility waited for hospice’s arrival from 09/01/23 12:30 PM to 09/01/23 4:30 PM. Hospice discharge summary reveals that the company received a call from the facility at 09/01/23 3:30 PM indicating that R1 was unresponsive and hospice doctor pronounced R1’s death at 4:35 PM. Regarding the allegation, “Staff did not get timely medical care for resident resulting in resident’s death, based on record review 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 this allegation.

An exit interview was conducted and a copy of this report was reviewed and left with Assistant Administrator Peggy Clark.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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