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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 09/02/2026
Date Signed: 09/02/2026 03:40:43 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
08/31/2026 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20260831153434
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: 156DATE:
09/02/2026
UNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Veronica GomezTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident developed pressure injuries due to staff neglect.
INVESTIGATION FINDINGS:
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On 09/02/26 at 12:00 pm Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA met with Administrator Veronica Gomez (staff #1/S1) as the purpose of today’s visit was explained.

The investigation consisted of the following: On 09/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, conservatorship documents, pre-appraisal dated: 02/02/26, Physicians report dated: 07/01/25 , needs and service plan dated: 07/18/26, medication list, wound care documentation, wound care initial visit note dated: 0814/26, hospice communication note dated: 7/24/26, and documented facility documentation. On 09/01/26 and 09/02/26 LPA conducted Interviews with (Staff #1-7/ S1-S7). On 09/02/26 LPA conducted interviews with residents #2-10 (R2-R10). On 09/01/26
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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 2
Control Number 11-AS-20260831153434
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: 09/02/2026
NARRATIVE
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and 09/02/26 LPA was unable to interview R1 as R1 is currently receiving outside services. On 09/01/26 and 09/02/26 LPA attempted to reach witness #1 (W1) but was unsuccessful. On 09/02/26 LPA spoketo witness #2 (W2), and conducted a review of all documents obtained.

The investigation revealed the following
Allegation: Resident developed pressure injuries due to staff neglect.
It is alleged that facility staff did not tend to a residents pressure injury in a timely manner which resulted in hospitalization. On 09/02/26 LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above and report they have not obtained any injury while living at this facility. Furthermore 9 of 9 residents did not report any concerns about the care they are receiving. On 09/01/26 and 09/02/26 LPA was unable to interview R1 as R1 is currently receiving outside services. On 09/02/26 LPA attempted to reach W1 but was unsuccessful. On 09/02/26 spoke to W2 regarding the allegation above, per W2 there are no concerns with the care R1 was being provided at the facility. On 09/01/26 and 09/02/26 LPA conducted Interviews with S1-S7 regarding the allegation above. 7 of 7 staff interviewed denied the allegation above and indicated that staff are trained on pressure injury prevention and recognition, and that in-services are conducted twice a month. Additionally, 7 of 7 staff stated that when a pressure injury is observed, the residents representative and Dr. are notified before care is provided. Per 7 of 7 staff, preventive measures such as 2 hour repositioning and skin care is implemented in addition to home health, hospice, or wound care services. On 09/02/26 LPA conducted a review of all documents obtained for R1. Per needs and service plan dated: 07/18/26, R1 was placed on concierge hospice care on 07/16/26 due to decline in health and pressure sore, soft wedges were to be placed between legs and back for better support. LPA reviewed facility documentation dated between May 2026- August 2026, per documentation R1's pressure injuries and wounds were being treated per Drs. orders and were healing. Per documentation dated 08/03/26 there was a meeting with W1, W2, caregivers, and facilities LVN to put a service plan of care for R1. Documentation dated 08/24/26, facility spoke to W1 regarding R1's current health condition. W1 was encouraged to send R1 out to the hospital so that the Dr. could decide the best wound treatment care. W1 agreed to that plan and hospice was made aware.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Exit interview conducted, and a copy of this plan was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
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