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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:02:58 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
01/14/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250114095525
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:
01/22/2025
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Peggy ClarkTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed.
INVESTIGATION FINDINGS:
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On January 22, 2025, Licensing Program Analyst, (LPA) Deborah Lee conducted an unannounced visit to this facility. LPA was met by Peggy Clark Administrator and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.
The investigation consisted of the following:

On January 22, 2025, Licensing Program Analyst (LPA) Deborah Lee toured facility, reviewed R1’s medication with MedTech’s, requested and received copies of the following: Staff roster dated 1/22/25, Resident Roster, R1’s Medication Administration Record (MAR) for November 2024, December 2024 and January 2025 and Med Tech Trainings and Certification (dated 1/10/25, 12/20/24, 11/15/24, 11/724, 6/26/23), and Nursing Note (dated 12/30/24), interviews with staff 1-3 and Administrator, interviews with R1-R5, observation of medication being given during meal time (11:45am).

Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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 5
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
01/14/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250114095525

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:
01/22/2025
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Peggy ClarkTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility staff did not assist resident with obtaining medication refill as needed
INVESTIGATION FINDINGS:
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On January 22, 2025, Licensing Program Analyst, (LPA) Deborah Lee conducted an unannounced visit to this facility. LPA was met by Peggy Clark Administrator and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.
The investigation consisted of the following:

On January 22, 2025, Licensing Program Analyst (LPA) Deborah Lee toured facility, reviewed R1’s medication with MedTech’s, requested and received copies of the following: Staff roster dated 1/22/25, Resident Roster, R1’s Medication Administration Record (MAR) for November 2024, December 2024 and January 2025 and Med Tech Trainings and Certification (dated 1/10/25, 12/20/24, 11/15/24, 11/724, 6/26/23), and Nursing Note (dated 12/30/24), interviews with staff 1-3 and Administrator, interviews with R1-R5, observation of medication being given during meal time (11:45am).

page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250114095525
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: 01/22/2025
NARRATIVE
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The allegation revealed the following:

Allegation: Facility staff did not assist resident with obtaining medication refill as needed

It is being reported that staff allowed the resident ran out of her medications without ensuring she had a refill or assist her with obtaining a refill.

On January 22, 2025, LPA Lee reviewed Nursing Notes(dated 12/30/24 at 10:00am) which revealed that S1 made several calls to in an attempt to ensure that R1 receive her refills. According to the note, communication to Pharmacy representative was made in addition to R1's doctor, and the responsible party.

On January 22, 2025 LPA Lee interviewed R1-R5, and of those interviewed 4 of 5 state that the staff always help them obtain refills to their medication. Additionally, 4 out 5 stated that they have never ran out of medication.

On January 22, 2025 LPA Lee interviewed staff 1-3 (S1-S3) and administrator (A1). Of those interviewed 3 out of 3 staff and Administrator stated that facility staff always assist residents in obtaining a refill of medication when needed.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of "Facility staff did not assist resident with obtaining medication refill as needed" found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of report was give to Peggy Clark Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250114095525
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: 01/22/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Facility staff did not dispense medications to resident as prescribed

On January 22, 2025, LPA Lee conducted a review of R1 service file including Medication Administration Record (MAR). Records revealed that R1’s cycle of medication was missed on the following dates: 12/30/24, 12/31/24, 1/1, 1/2/25, 1/3/25, 1/4/25, 1/5/25, and 1/6/25.

LPA Lee interviewed S1-S3 and Administrator (A1). 3 out 3 staff and administrator state that medication is dispensed as prescribed and on time, however, R1 changed her insurance and doctor who sent prescription to an outside pharmacy which delay process of them getting the medication on time. LPA interviewed Residents 1-5 (R-1 thru R-5). Of those interviewed, 4 out of 5 they receive their medication as prescribed and on time. According to the information gathered there is sufficient evidence to support the allegation mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.)

Deficiencies are issued and an exit interview is conducted with Peggy Clark. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250114095525
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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
87465
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
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Licensee will ensure compliance by developing a plan to prevent medication is missed due to resident changing doctor or insurances without letting facility know. Plan to be emailed to LPA by due date Deborah.Lee@dss.ca.gov.
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Based on interviews and records review, the licensee did not comply with the section cited above as resident R1 prescribed medication was missed on 12/30/24-1/6/2025 which poses/posed a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5