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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:23:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240215081652
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: 147DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Peggy ClarkTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility failed to seek medical attention in a timely manner.
Facility staff failed to report an incident to licensing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Assistant Administrator (S9: Peggy Clark). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: An initial 24-hour health and safety visit was conducted by LPA Dabuet on 02/16/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 02/16/24), Staff Roster & Work Schedules (dated: 02/01/24), Facility House Rules (dated: 2023), Admissions Agreement (dated 05/20/22), Physician’s Report (dated 04/13/23), Resident Appraisal (dated: 01/05/24; 02/06/24 & 09/30/23), Functional Capability Assessment (dated: 01/05/24), Identification and Emergency Information (dated: 05/17/22), Physicians Orders Medications (dated: 02/16/24), Record of Admission (dated: 05/26/22 & 06/01/22), Physicians Report (dated: 03/29/23), Unusual Incident/Injury Report (dated: 01/03/22; 09/14/22; 09/16/23; 01/30/23; 02/02/24; 02/15/24), and Facility Sketch (dated: 2015).
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24);Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1-#2 (R1-R2).

INVESTIGATION REVEALED THE FOLLOWING:



Allegation #2: Facility failed to seek medical attention in a timely manner.

It is alleged that facility staff failed to seek timely medical attention for resident #1 (R1). The complainant reported on 2/02/24, (R1) was found in (R1’s) bedroom completely unclothed, vomiting, and bleeding from (R1’s) private parts.



This investigation revealed that Resident #1 (R1) sometime in January 2024 was sent out to the hospital due to having difficulty breathing and had blood in (R1’s) urine. (R1) was diagnosed with a Urinary Tract Infection (UTI). On 02/02/24, the facility informed family representative witnesses witness #1-#3 (W1-W3) that (R1) was complaining of abdominal pain. (R1) was transported by family member witness #2 (W2) to (R1’s) primary doctor and later transported by ambulance to Long Beach Medical Center Hospital Emergency Department and was examined.

On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-#8 (S1-S8) all verified they were aware of (R1’s) UTI health condition and occasionally would complain about abdominal pains. Interviews of staff revealed (R1) was discovered in (R1’s) room at approximately 07:00 am in bed with complaints of abdominal pain with bloody discharge and vomit.

On 05/22/24, at 11:26 am, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed family member witness #2 (W2), who indicated (W2) received a call approximately between 12:00 pm – 01:00 pm who was notified by the facility of (R1’s) urgent condition.
(Evaluation Report continues LIC 9099-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
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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(W2) stated the facility staff only indicated (R1) was complaining of abdominal pain and did not indicate (R1) needed to be medically evaluated. Moreover, the staff withheld information about (R1’s) additional symptoms of bloody discharge or vomited.

On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7) who stated (R1) was admitted at approximately 04:46 pm on 02/02/24. (R1) would have been in pain and (R1’s) prognosis would not have changed, however, (R1) may have been spared additional pain associated with (R1’s) prognosis of Spinal Muscular Atrophy (SMA) if (R1) was brought in for medical attention much earlier.

Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in “Facility failed to seek medical attention in a timely manner” is found to be SUBSTANTIATED.

Allegation #3: Facility staff failed to report an incident to licensing.

It is alleged that facility staff failed to report an incident involving resident #1 (R1) and resident #2 (R2). The complainant reported the facility staff failed to provide an appropriate level of care and supervision, which resulted in (R1) being sexually assaulted by (R2) on 02/02/24. There was no report of the incident to Community Care Licensing (CCL).



On 04/29/24 at 12:49 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed Administrator (A1). (A1) indicated as the administrator, (A1) was responsible for submitting Special Incident Reports (SIR) to (CCL) and overseeing the facility. (A1) indicated there were cameras in the common areas and hallways, which are only accessible to management. (A1) indicated the cameras are not monitored daily, and it is only reviewed when incidents occur to assist with the completion of (SIRs). However, if incidents were not reported then the cameras would not be reviewed. (A1) indicated on 02/02/24 the morning staff informed (A1) of the incident between (R1) and (R2).

(Evaluation Report continues LIC 9099-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
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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On 02/16/24, the Department conducted a health and safety inspection visit at the facility. During the inspection (A1) provided copies of Special Incident Reports (SIR) associated with (R1 and R2) (dated: 02/02/24 and 02/15/24). The facility has not revealed its submission of these incidents to (CCL) via fax receipts (also known as confirmation pages).

Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in "Facility staff failed to report an incident to licensing" is found to be SUBSTANTIATED.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted with Peggy Clark 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
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2024 and conducted by Evaluator Ernand Dabuet
COMPLAINT CONTROL NUMBER: 11-AS-20240215081652

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: 147DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Peggy ClarkTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
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9
Resident was sexually assaulted while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Assistant Administrator (S9: Peggy Clark). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: An initial 24-hour health and safety visit was conducted by LPA Dabuet on 02/16/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 02/16/24), Staff Roster & Work Schedules (dated: 02/01/24), Facility House Rules (dated: 2023), Admissions Agreement (dated 05/20/22), Physician’s Report (dated 04/13/23), Resident Appraisal (dated: 01/05/24; 02/06/24 & 09/30/23), Functional Capability Assessment (dated: 01/05/24), Identification and Emergency Information (dated: 05/17/22), Physicians Orders Medications (dated: 02/16/24), Record of Admission (dated: 05/26/22 & 06/01/22), Physicians Report (dated: 03/29/23), Unusual Incident/Injury Report (dated: 01/03/22; 09/14/22; 09/16/23; 01/30/23; 02/02/24; 02/15/24), and Facility Sketch (dated: 2015).
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24); Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1 #2 ( R1-R2).

INVESTIGATION REVEALED THE FOLLOWING:



Allegation #1: Resident was sexually assaulted while in care.

It is alleged that facility staff failed to provide an appropriate level of care and supervision which resulted in Resident #1 (R1) being sexually assaulted by Resident #2 (R2) on 02/02/24 while in care at the facility.

On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-8 (S1-S8) who were not able to validate that a sexual assault had occurred between (R1) and (R2) on 02/02/24. Six (6) out of nine (9) facility staff have never witnessed (R2) inappropriate or aggressive behavior with other residents or staff.

The Long Beach Police report revealed the facility staff provided inconsistent statements to law enforcement. When interviewed by Investigator Sonia Sandoval, Staff #1 (S1) admitted knowledge of the incident despite initially denying knowledge to law enforcement. The police report indicated Long Beach Police Officer (LBPO) witness #8 (W8) asked (R1) if (R2) had been assaulted or raped by (R2) and (R1) stated, “No.”

On 03/25/24, 04/16/24, and 05/22/24 between 08:09 am – 03:15 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (4) out of (4) family representative witnesses #1-#4 (W1-W4) revealed they never observed anything concerning with the level of care or supervision.

(Evaluation Report continues LIC 9099-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
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7), who confirmed (R1) underwent a thorough examination upon admission and the tests completed would have captured signs of trauma or bruising were not present. Furthermore, the additional symptoms (R1) exhibited at the facility may have been symptoms associated with (R1’s) diagnosis.
On 06/26/24, at 07:57 am, Investigator Sonia Sandoval interviewed Long Beach Police Department Special Victims Section Detective witness #9 (W9), who claimed the investigation had been closed since no proven crime had occurred.

There were no actual witnesses to validate that a crime had happened nor demonstrative evidence presented as evidence.

Based on the evidence gathered interviews conducted, and records reviewed, 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; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident was sexually assaulted while in care” is found to be UNSUBSTANTIATED.

An exit interview was conducted with Peggy Clark, and a hard copy of the report is provided.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20240215081652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social
functioning... appropriate assistance is provided when such observation reveals unmet needs. When changes such as... deterioration... a physical health condition is observed, resident's responsible
person...the licensee shall ensure that such changes...brought to the attention of the resident's physician...
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Observation of the Resident” and implement a plan detailing how Licensee/Administrator will ensure all residents are regularly observed for changes. 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: Facility staff had knowledge of (R1’s) health condition with UTI associated with severe abdominal pains, and failed to seek medical attention in a timely manner. 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
CCR
87211(a)(B)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
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Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with incident resident #1 and #2. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. 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
LIC9099 (FAS) - (06/04)
Page: 8 of 8