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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:17:18 PM


Document Has Been Signed on 08/30/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:GOMEZ, VERONICAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 147DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Veronica Gomez & Peggy ClarkTIME COMPLETED:
01:15 PM
NARRATIVE
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On 08/30/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #1 (A1) Veronica Gomez and Assistant Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is in reference to a complaint about Palmcrest Grand Residence Complaint Number 11-AS-20240215081652.

During the investigation conducted by California Department of Social Services (CDSS) Investigation Bureau (IB) investigator Sonia Sandoval, it revealed that (A1) withheld information. (A1) stated resident #2 (R2) was never evicted from the facility and informed (R2’s) family representative (R2) was able to return to the facility. Information provided to (IB) Investigator Sandoval claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the of incident 02/02/24. In addition, (A1) stated resident #1 (R1’s) family representative was immediately notified of the condition (R1) was found in abdominal pain. Nonetheless, (R1’s) family representative claimed notification of (R1’s) condition was received after 1300 hours (R1) was discovered by staff of abdominal pain at 0700 hours. (R1’s) family representative was not informed of the additional symptoms (R1) exhibited which included vomiting, diarrhea, and bloody discharge.

(A1) provided wrongful removal of resident #2 (R2). (A1) indicated (R2) exhibited aggressive behavioral outbursts and was deemed a safety concern. There were no reports of aggressive behavior by any of the staff present during the incident on 02/02/24. In addition, (R2’s) family representative was notified after (R2) had been transported to the VA hospital that (R2) was not welcome to return to the facility and was not provided an Eviction Notice.

The investigation revealed that (A1) obstructed the investigation. Facility staff disclosed fear of retaliation by (A1) and stated (A1) treated them differently for cooperating with IB Investigators.

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 08/30/2024
NARRATIVE
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Information gathered indicated when law enforcement went to the facility, (A1) alerted the staff and instructed the staff not to say anything as there was no proof anything had occurred on the incident 02/02/24. (A1) stated to have not reported the incident to law enforcement because (A1) did not observe any signs of an assault. Despite this, (A1) stated to the Long Beach Police Department (LBPD) Detective (R2) had been removed and was not allowed back into the facility due to the incident.

Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (A1) failed to carry out the responsibilities and duties of an administrator by withholding information, wrongful removal of residents, and obstruction of an investigation. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D.

An exit interview was conducted with Veronica Gomez, Administrator, and a hard copy of the report along with appeal rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/30/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87413(3)

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87413(3) Personnel – Operations
(3) The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice.

This requirement is not met as evidenced by:
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Personnel Operations” and implement a plan detailing how Licensee/Administrator will ensure all staff are encourage to report incidents. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This violation poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/13/2024
Section Cited
CCR87405(b)(1)(2)(5)

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87405 Administrator – Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (d) The administrator shall have the qualifications..(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (5) Good character and a continuing reputation of personal integrity.
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Administrator Qualificaitons and Duties” and will complete an Etnics Training in Senior Care. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews by IB, (A1) failed to carry out the policies and ability to conform to the applicable laws, rules and regulations. This violation poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/30/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87224(b)(c)

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87224 – Eviction Procedures (b) The licensee may, grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility. (c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Eviction Procedures” and implement a plan detailing how Licensee/Administrator will ensure all residents are given proper written eviction notice and submit for approval from CCL. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews by IB, (A1) wrongfully evicted (R2) by transporting to VA hospital and denied accessed to return to the facility. This violation poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4