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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:58:16 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
04/01/2022 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20220401095058
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: 133DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Veronica GomezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not supervise residents resulting in multiple falls
Resident care needs are not being met
Facility failed to safeguard resident’s property
Facility is short staffed
Facility has a lack of supplies
INVESTIGATION FINDINGS:
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On 05/16/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Administrator, Veronica Gomez, and the purpose of today’s visit was explained.
During today’s visit LPA received and reviewed additional documents pertinent to the investigation. The additional documents include the residents staff notes regarding behavior and incidents and Re-Assessments.
On a previous visit conducted on 05/02/24, LPA toured the facility, interviewed Staff S1-S8, interviewed Residents R5- R16, and received documents pertinent to the investigation. The documents received include Staff Roster, Resident Roster, Staff Schedule, SIRs regarding falls, Admission Agreement, Resident Needs and Service Plans, Physicians Reports, Pre-Admission Evaluation, and Safeguard of Residents valuables and property.
During a previous visit conducted by LPA Senaha on 04/04/22, LPA Senaha conducted a plant inspection of the facility, received a copy of the Resident Roster, Staff roster, and documents for Residents R1-R4.
CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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 8
Control Number 11-AS-20220401095058
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: 05/16/2024
NARRATIVE
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On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22.

The investigation revealed the following:

Allegation: Staff do not supervise residents resulting in multiple falls


It is alleged as a result of being short staffed resident fall due to lack of supervision.
During file review, LPA reviewed Special Incident Reports (SIR) regarding falls. During the facility tour, LPA observed some rooms have a lower bed to make it easier for residents to get in and out of to help prevent falls. Additionally, LPA observed some rooms have fall mats that are placed next to the bed once the resident is in bed.
During interviews with Staff S1-S8, were asked how often are residents with fall plans checked on, eight (8) out of eight (8) stated they are checked every fifteen (15) minutes.
During interviews with Residents R3, R5-R16, were asked if they have had any falls while living in the facility, nine (9) out of thirteen (13) stated they have not had any falls while living here. Three of the four residents who experienced falls stated the falls happened years ago, and the other stated theirs was a minor fall. Additionally, during interviews with Residents R3, R5-R16, were asked if they feel staff supervise residents, thirteen (13) out of thirteen (13) feel staff supervise residents.
CONTINUED ON LIC9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20220401095058
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: 05/16/2024
NARRATIVE
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During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Resident care needs are not being met.


It is alleged resident’s needs are not being met and are not being changed or bathed in a timely manner.
During the facility tour, LPA observed the residents in the facility are placed in a room in a certain area depending upon their needs. There are three (3) memory care units, a hallway of resident that are on hospice, an assisted living area, and an independent living area. Each area is staffed with caregivers according to the resident’s needs. LPA reviewed the Physicians Report, Appraisal, and Needs and Service Plan for eight (8) residents and reviewed where their placement is at in the facility based on the level of assistance they require.
During interviews with Staff S1-S8, were asked if they feel residents care needs are being met, eight (8) out of eight (8) stated they believe residents care needs are being met.
During interviews with Residents R3 and R5-R16, were asked if they felt their care needs are being met, thirteen (13) out of thirteen (13), stated their care needs are being met.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
CONTINUED ON LIC9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20220401095058
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: 05/16/2024
NARRATIVE
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Allegation: Facility failed to safeguard resident’s property
It is alleged residents are missing personal items such as jewelry.
During the facility tour, LPA observed in residents’ room a drawer with a lock on it to secure their personal belongings. During record review, LPA reviewed the Admission Agreement that states on page 8 number 27 “the resident or representative have the option to record and document all personal property brought into the facility on LIC621 for the facility to safeguard resident personal belongings and other property.” Additionally, it states “The facility is not liable for any personal items which are not contained in the resident inventory list.”
During an interview with the Administrator S1, was asked how resident’s personal belongings are safeguarded, S1 stated every room has a locked drawer to secure their personal belongings in and the family is asked to inventory items coming in on a LIC621. Additionally, S1 stated that they tell new residents and their family not to bring expensive jewelry or large sums of money to the facility.
During interviews with Staff S2-S8, were asked how residents personal belongings are safeguarded, seven (7) out of seven (7), stated they encourage residents to close and lock their room doors, and to secure items in their drawer with a lock.
During interviews with Residents R3, R5-R16, were asked if they had any items go missing, ten (10) out of thirteen (13) stated they have not had any item go missing. Additionally, LPA asked the Residents R3, R10, and R16, what items they had missing and how long ago, a resident stated they had two (2) pieces of computer paper go missing a long time ago, another stated they had seashells go missing a while ago, and another stated they has some clothes go missing 3 years ago.
During the course of the investigation, LPA was unable to find evidence to support CONTINUED ON LIC9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20220401095058
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: 05/16/2024
NARRATIVE
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the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Facility is short staffed


It is alleged most days the facility is short staffed, one caregiver for each floor and in some cases one caregiver for the entire building to the point residents are assisting other residents with care and mobility needs.
During record review LPA reviewed the Staff Schedule and observed there were eleven (11) caregivers scheduled to work. Additionally, LPA reviewed the staff schedule for April 2022 and observed for the AM shift seven (7) caregivers and a Med Tech was scheduled, for the PM shift ten (10) caregivers were scheduled and a Med Tech, and for the Noc shift five (5) caregivers were scheduled. During the facility tour, LPA observed all eleven (11) caregivers throughout the facility.
During interviews with Staff S1-S8, were asked if they feel there are enough staff to meet residents needs, eight (8) out of eight (8) stated yes, they feel there are enough staff.
During interviews with Residents R3, R5-R16, were asked if they feel there are enough staff to meet the residents needs, twelve (12) out of thirteen (13), stated they feel there are enough staff to meet their needs and one resident was not sure.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

CONTINUED ON LIC9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20220401095058
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: 05/16/2024
NARRATIVE
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Allegation: Facility has a lack of supplies
It is alleged the facility is often low on supplies, diapers, and other care products.
During the facility tour, LPA observed four (4) different rooms with hygiene supplies and incontinent care supplies stored within. LPA observed an ample supply of products. During an interview with Administrator S1, was asked if they feel there is enough supplies to meet resident’s needs, S1 stated they order products monthly and are always available to residents. Additionally, diapers are covered by the insurance and there are extra available if needed and hospice usually supplies wipes which we have extra available as well.
During interviews with Staff S2-S8, were asked if they feel there is enough supplies to meet resident’s needs, seven (7) out of seven (7) stated the facility has hygiene products and incontinent products available for residents.
During interviews with Residents R3, R5 – R16, were asked if hygiene or incontinent products are supplied to them, thirteen (13) out of thirteen (13) stated they know there are products available if they need them and the facility has a large supply.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During today's visit LPA did not observe or cite any deficiencies.

LPA conducted an exit interview with Executive Director, Veronica Gomez, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8