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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 10/24/2025
Date Signed: 10/24/2025 04:29:05 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
06/10/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250610120640
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: 141DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Peggy Clark/AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff sexually assaulted a resident while in care
INVESTIGATION FINDINGS:
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On 10/24/2025 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Peggy Clark/ Facility Administrator. LPA explained the purpose of this visit.


Investigation Consisted of: the department conducted the following interviews: Administrator Interview (A#1), Resident Interviews (R#1-R#4), Facility Staff Interviews (S#1-S#5), and Witness Interview (W#1). The department gathered the following documentation: Copy of Long Beach Policy Department (LBPD) report #250025649 and Sexual Assault Forensic Medical Exam (SART) dated:6/8/25 and copy of (R#1)'s Physician's report for Residential Care Facilities for the Elderly (RCFE) dated 6/9/25.

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: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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 4
Control Number 11-AS-20250610120640
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: 10/24/2025
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff sexually assaulted a resident while in care

The details of the complaint alleged that facility staff (S#1) sexually assaulted (R#1) at the facility.

On October 17, 2025, at approximately 1:00 PM, during a records review, the department found a copy of Long Beach Police Department (LBPD) report #250025649, dated June 8, 2025. This report details an incident where, on June 8, 2025, at around 4:00 PM, LBPD officers responded to a memory care unit following a report of sexual assault. The report indicated that the victim (R#1) claimed to have been sexually assaulted by the suspect (S#1). LBPD officers interviewed (R#1), who stated that approximately three weeks prior, (S#1) had entered their room twice to administer medication once around 9:00 PM and again around 10:00 PM. (R#1) mentioned that the following morning, they woke up experiencing significant vaginal pain. During the interview, (R#1) provided a tissue that they had used to clean their private area. A Sexual Assault Forensic Medical Exam (SART) was subsequently performed on (R#1), but the examination revealed no physical findings. Additionally, the department reviewed the copy of (R#1)'s Physician's report for Residential Care Facilities for the Elderly (RCFE) dated 6/9/25. The department observed that (R#1) has a cognitive impairment that might influence their decision-making and behavior.

On 8/28/25, at approximately, 9:45 am, the Department interviewed facility administrator (A#1), she stated that when (R#1) move into the facility, they were placed in the assisted living section, however, it was determined that (R#1) needed a higher level of care, therefore, (R#1) transitioned to the memory care unit and resided there for approximately four weeks before moving out.

Evaluation Report continues LIC 9099-C

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

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250610120640
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: 10/24/2025
NARRATIVE
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On September 4, 2025, at approximately 11:00 AM, the Department interviewed Facility Staff #1 (S#1), who confirmed that they were the medication technician assigned to the Memory Care Unit (MC1), where Resident #1 (R#1) resided. At around 7:00 PM, (S#1) attempted to administer medication to (R#1), who refused to take it. The medication was subsequently discarded, and the refusal was documented in the electronic log. (S#1) denied having any physical contact with (R#1) during that shift or previous shifts. (S#1) also denied the allegation of sexual assault, expressing confusion and attributing the claim to (R#1)'s cognitive impairment and possibly the missed medication.

On August 4, 2025, at approximately 3:00 PM, the Department interviewed Witness #1 (W#1). (W#1) stated that (R#1) had lived at the facility for about six weeks. (R#1) initially moved into the assisted living unit but was later transferred to the memory care unit for 24-hour care. (W#1) reported being notified of the incident by the police. When asked, (R#1) told (W#1) that someone was entering their room and sexually assaulting them. (W#1) expressed doubt about the allegations but chose to wait for the results of the Sexual Assault Forensic Medical Exam (SART). (W#1) also recalled that about two weeks after (R#1) moved in, (R#1) made a similar disclosure but was unable to provide further details. (W#1) believed the statements may have been influenced by (R#1)’s cognitive impairment.

On August 5, 2025, at approximately 10:00 am, the Department interviewed Resident #1 (R#1), who was unable to recall how long they had lived at the facility. (R#1) shared that before admission, they had experienced a fall that resulted in hospitalization, after which they began noticing a gradual memory decline. When asked if they knew the reason for the interview, (R#1) stated they did not. When asked if anything had occurred to them at the facility, (R#1) stated that several things had happened during their stay. (R#1) reported believing they had been sexually assaulted, explaining that they noticed some residue coming from their private area. (R#1) was unable to recall any additional details about the alleged assailant or the incident.


Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250610120640
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: 10/24/2025
NARRATIVE
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On August 28, 2025, at approximately 11:00 am, the Department interviewed residents 2-4 (R#2-R#4), (2) out of (3) stated that they feel safe living at the facility and the facility staff are ‘good’ to them.

On August 28, 2025, at approximately 10:00 am, the Department interviewed facility staff 2-5 (S#2-S#5), (4) out of (4) stated that they have never observed (S#1) or other facility staff interact inappropriately with (R#1) or any other residents in care.

During this investigation, LPA did not find sufficient evidence 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 Peggy Clark/Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4