198602069-4-9-2026-11-AS-SCIS-DUFV4F-20260526160609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/09/2026
Date Signed: 04/09/2026 03:58:42 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
11/04/2025 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 11-AS-20251104161938

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	GOMEZ, VERONICA		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 150	DATE:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Vernonica Gomez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff restrained a resident to a wheelchair.

INVESTIGATION FINDINGS:

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On 4/9/2026 at 1:07 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation. LPA identified herself and met with Veronica Gomez, who was informed of the purpose of the visit.

The investigation consisted of the following:

On 11/10/2025, the Department toured the facility’s kitchen, dining area, and the 1st and 3rd floors. During the kitchen tour, LPA did not observe any crawling or flying insects. The kitchen appeared clean and sanitary. The Department also interviewed Staff 1 through Staff 3 (S1–S3) and Residents 1 and 2 (R1–R2), and obtained documents for review.

On 4/9/2026 at 1:00 PM, the Department conducted additional interviews with Residents 4 through 6 (R4–R6) and Staff 4 through Staff 9 (S4–S9).

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

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 3

Control Number 11-AS-20251104161938

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: 04/09/2026

NARRATIVE

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Allegation 1: Staff restrained a resident to a wheelchair.

Interviews with Staff 1 and Staff 2 indicated that S1 had restrained Resident 1 (R1) in their wheelchair by using the buckle. Staff 3 through Staff 8 (S3–S8) stated that they had not seen any staff restraining residents in their wheelchairs using buckles or any other devices. Some staff said they had heard rumors in the past but had not witnessed anything themselves.

On 11/10/2025, LPA attempted to interview Residents 1 and 2 (R1–R2); however, both residents were unable to engage in a clear conversation. On 4/9/2026 at 2:00 PM, LPA interviewed Residents 3 through 9 (R3–R9). All seven residents stated that staff had never restrained them in any way, including in their wheelchairs.

During the visit on 4/9/2026, the Department did not observe any residents restrained in their wheelchairs. However, a review of records showed that Resident 1 (R1) sustained injuries consistent with being restrained in their wheelchair.

Interviews and record reviews showed that the licensee did not have a physician’s order for postural supports, and such supports should not have been used by staff. Staff 1’s records confirmed that S1 did strap R1 into their wheelchair, which resulted in injuries.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met.

Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title (22), Division (6) is being cited on the attached LIC9099-D.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20251104161938

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: 04/09/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2026 Section Cited CCR 87608(a)(5)	1 2 3 4 5 6 7	87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself.....	1 2 3 4 5 6 7	The licensee has agreed to provide training to all staff members on the cited regulation and personal rights of residents in care. Proof of training was provided at the time of visit on 11/11/2025 during visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by:Based on interviews and record review the licensee did not have a physician’s order for Postural Supports and records revealed that S1 did strap R1 to their wheelchair which resulted in injuries to R1. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

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