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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 10/10/2025
Date Signed: 10/10/2025 02:23:53 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, 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
08/11/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250811090913
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: 140DATE:
10/10/2025
UNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Veronica Gomez/AdministratorTIME COMPLETED:
02:23 PM
ALLEGATION(S):
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Licensee does not ensure that staff have criminal clearance
INVESTIGATION FINDINGS:
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On 10/10/2025 at approximately 9:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Veronica Gomez/Administrator. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator(A#1). LPA obtained and reviewed the following documents: Client Roster dated: 10/1/25, Personnel Report or LIC 500 dated: 9/1/25.




Evaluation Report continues LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
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-20250811090913
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: 10/10/2025
NARRATIVE
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Investigation Revealed the Following:

Allegation: Licensee does not ensure that staff have criminal clearance

The detail of the complaint is alleging a maintenance worker is associated with a false name and criminal record clearance number.


On October 10, 2025, at approximately 1:00 PM, during a review of facility records, Licensing Program Analyst (LPA) Iniguez reviewed the Personnel Report (LIC 500) dated September 1, 2025. Upon review, LPA Iniguez observed that (MW#1) was not listed on the LIC 500 since they are a third party provider.

On October 10, 2025, at approximately 10:00 AM, during an interview, the facility administrator (A#1) stated that individual (MW#1) is an outside contractor hired by the facility owner and is not a facility employee. According to (A#1), (MW#1) is present at the facility approximately four times per week and remains on-site for about seven hours per visit. (A#1) confirmed that (MW#1) performs contracted maintenance work inside the facility. Additionally, (A#1) stated that when (MW#1) is inside the facility, they are never alone inside residents’ rooms and always work in the common areas, where there is consistent supervision by facility staff.

On October 10, 2025, at approximately 11:00 AM, during interviews with facility staff, (5) out of (5) staff members stated that they are familiar with individual (MW#1) and observe them at the facility approximately three to four times per week. Additionally, all five staff members reported that whenever they have seen (MW#1), the individual is observed in the common areas where there is consistent supervision by facility staff. Staff further stated that when residents request the maintenance person to enter their rooms, (MW#1) are never unaccompanied, there is always a caregiver present during those instances.


Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250811090913
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: 10/10/2025
NARRATIVE
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During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.



An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3