198602069-11-13-2024-11-AS-RORN-DB7USX-20241120145103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 11/13/2024
Date Signed: 11/13/2024 06:42:44 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
06/25/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20240625141047

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: 143	DATE:	11/13/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Peggy Clark and Veronica Gomez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident falling and sustaining multiple injuries

INVESTIGATION FINDINGS:

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CCLD conducted an unannounced complaint visit on Wednesday, November 13, 2024, upon arrival at the facility. The department called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department met with Assistant Administrator Peggy Clark and Administrator Veronica Gomez. The department explained the purpose of today's visit.

The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-6 (S1-S6), residents 1-13 (R1-R13), witnesses 1-4 (W1-W4), and the complainant. The department asked questions relevant to the nature of the complaint. The department toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visits. Residents' records were requested observed, and reviewed.

See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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-20240625141047

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: 11/13/2024

NARRATIVE

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Continued LIC9099-C page 2

The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Long Beach Memorial Hospital Medical Records, Windsor Convalescent Hospital Medical Records, Long Beach Police Department Call Log, Special Incident Reports, In-Service Training, Training on Reporting Dependent Adult and Elder Abuse, and any Ongoing Training.

Allegation: Lack of supervision resulted in the resident falling and sustaining multiple injuries
The department interviewed staff members 1-6 (S1-S6), residents 1-13 (R1-13), and witnesses 1-4 (W1-W4). Based on files, and interviews, there was insufficient evidence to prove that the facility was responsible for neglect or lack of care and supervision, leading to the resident's unwitnessed fall at the facility on June 22, 2024, which resulted in multiple injuries. According to the resident's medical records from Long Beach Memorial Hospital, the resident sustained a stroke, which may have contributed to the unwitnessed fall. Staff, the resident's physician, and witness statements indicated no change in the resident condition that would have raised any concern for the resident to fall. The resident was documented as ambulatory and able to dance during a replacement assessment on May 16, 2024. The resident's physician confirmed that upon discharge from Windsor Convalescent Hospital on May 25, 20024, the resident was ambulatory and walked with ease. The physician added that the resident frequently danced while at the hospital.

Investigation revealed the following:
Based on the evidence received from the medical records, staff, resident's physician, the residents, and witnesses there was sufficient staff on duty in the memory care unit at the time of the fall. Staff immediately responded to the resident's room upon hearing a loud sound, provided assistance, and called 911 promptly. The staff took all necessary precautions to assist the resident. The staff could not have prevented the resident from falling. The allegation of neglect lack of care and supervision leading to the resident falling and sustaining multiple injuries was unsubstantiated.

See the continued LIC9099-C page 3.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240625141047

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: 11/13/2024

NARRATIVE

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Continued LIC9099-C page 3

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to the Administrator Peggy Clark.

There were no deficiencies cited.

An exit interview was conducted

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

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