198602069-6-10-2024-11-AS-RORN-D6CMLS-20240618094245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 05/31/2024
Date Signed: 06/10/2024 10:09:28 AM

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 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: 135	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Mray Salcedo		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Resident assaulted another resident

INVESTIGATION FINDINGS:

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On 05/31/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Director of Admissions, Mary Salcedo, and the purpose of today’s visit was explained.

During a visit on 05/16/24, 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 of residents.
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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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-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: 05/31/2024

NARRATIVE

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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.
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: Resident assaulted another resident

It is alleged Resident R1 was ‘beat up’ by resident R2 resulting in R1 being transported to the hospital for injuries.
During an interview with the former Administrator, conducted by Investigator Laura Garcia, stated R1 is a wanderer and wandered into R2’s room while they were asleep. R2 woke up, was startled, and pushed R1 who fell.
During file review, LPA reviewed a Special Incident Report (SIR), that was submitted regarding the incident that stated Saff was performing rounds and when R1 was not in their room Staff started to look for R1 and was calling their name, when they heard a R1 cry out loud. Staff observed R1 coming out of R2’s room. R2 said they were asleep, got startled, and pushed R1. The Long Beach Police Department was called out and the responding officer did not make a report due to the nature of the incident. During record review of Resident’s R1 and R2’s Physician Report, Needs and Service Plan, Resident Appraisal, and Staff Notes, LPA observed neither resident has a history of aggressive behavior, nor any previous altercations with other residents.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 05/31/2024

NARRATIVE

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During interviews with Staff S1-S8, were asked if physical altercations occur between residents, eight (8) out of eight (8) stated physical altercations do not usually occur they have had verbal altercation on occasion. Additionally, staff S1-S8 were asked how they de-escalate altercations between residents, eight (8) out of eight (8) stated they separate the residents and talk with them till they calm down, and in many instances when asked what the altercation was regarding, they don’t remember.
During interviews with Residents R3, and R5-R16, were asked if they have had, observed, or heard of altercations between residents, eleven (11) out of thirteen (13) stated they have not had, observed, or heard of any altercations. Additionally, three (3) of the thirteen (13) stated they have heard residents yelling at each other and staff come right away.
During an interview with Resident R1, conducted by IB Investigator Laura Garcia, was asked about neglect/lack of supervision leading to physical abuse, R1 denied any type of abuse or neglect while residing in the facility. R1 stated “I was fine, they took care of me, I have no complaints.”

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.

An exit interview was conducted with Director of Admissions, Mary Salcedo, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

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