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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 04/22/2025
Date Signed: 04/22/2025 01:20:38 PM

Document Has Been Signed on 04/22/2025 01:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR/
DIRECTOR:		GOMEZ, VERONICAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 262TOTAL ENROLLED CHILDREN: 0CENSUS: 144DATE:
04/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Peggy ClarkTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On April 22, 2025, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is reference with complaint #11-AS-20240215081652 and the Case Management visit on August 30, 2024, with Palmcrest Grand Residence.

During the investigation conducted by California Department of Social Services (CDSS) Investigation Bureau (IB) investigator Sonia Sandoval, it revealed that (A1) withheld information. (A1) stated that resident #2 (R2) was never evicted from the facility and informed that (R2’s) family representative (R2) was able to return to the facility. Information was provided to (IB) Investigator Sandoval, who claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the incident of 02/02/24. In addition, (A1) stated resident #1 (R1’s) family representative was immediately notified of the condition (R1) was found in abdominal pain. Nonetheless, (R1’s) family representative claimed notification of (R1’s) condition was received after 1300 hours (R1) was discovered by staff of abdominal pain at 0700 hours. (R1’s) family representative was not informed of the additional symptoms (R1) exhibited, which included vomiting, diarrhea, and bloody discharge.

(A1) provided wrongful removal of resident #2 (R2). (A1) indicated (R2) exhibited aggressive behavioral outbursts and was deemed a safety concern no reports of aggressive behavior by any staff present during the incident on 02/02/24. In addition, (R2’s) family representative was notified after (R2) had been transported to the VA hospital that (R2) was not welcome to return to the facility and was not provided an Eviction Notice.
(Evaluation Report continues LIC 809-C)
Janae HammondTELEPHONE: (424) 544-1027
Ernand DabuetTELEPHONE: (323) 629-5526
DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/22/2025
NARRATIVE
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The investigation revealed that (A1) obstructed it. Facility staff disclosed fear of retaliation from (A1) and stated that (A1) treated them differently for cooperating with IB Investigators.

Information gathered indicated when law enforcement went to the facility, (A1) alerted the staff and instructed the staff not to say anything as there was no proof anything had occurred on the incident 02/02/24. (A1) stated to have not reported the incident to law enforcement because (A1) did not observe any signs of an assault. Despite this, (A1) stated to the Long Beach Police Department (LBPD) Detective (R2) had been removed and was not allowed back into the facility due to the incident.

Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (A1) failed to carry out the responsibilities and duties of an administrator by withholding information, wrongful removal of residents, and obstruction of an investigation. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D.

An exit interview was conducted with Peggy Clark, Administrator, and a hard copy of the report along with appeal rights.

This Complaint Investigation Report LIC 809 and LIC 809C&D dated 04/22/25 superseded the original LIC 809 LIC 809C&D reports dated 08/30/24 ***

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 01:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2024
Section Cited
CCR
87413(a)(3)

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87413 Personnel – Operations (a) In each facility: (3)The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice.

This requirement is not met as evidenced by:
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Personnel Operations” and implement a plan detailing how Licensee/Administrator will ensure all staff are encourage to report incidents. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This poses a potential health, safety or personal rights risk to persons in care.
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Proof of correction sent via email 09/13/24 of completed Incident Report Staff Training.
Type B
04/29/2025
Section Cited
CCR87405(d)(5)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d).... If the licensee is also the administrator, all requirements... shall apply. (5) Good character and a continuing reputation of personal integrity.
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Administrator Qualificaitons and Duties” and will complete an Ethics Training in Senior Care. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. This violation poses a potential health, safety or personal rights risk to persons in care.
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Proof of correction sent via email 09/13/24 of completed Values, Ethics and Code of Conduct Training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae HammondTELEPHONE: (424) 544-1027
Ernand DabuetTELEPHONE: (323) 629-5526

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025

LIC809 (FAS) - (06/04)
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