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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002008
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:12:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231106170848
FACILITY NAME:PALM VILLAGEFACILITY NUMBER:
306002008
ADMINISTRATOR:LUZVIMINDA BRIMBUELAFACILITY TYPE:
735
ADDRESS:13902 CLINTON ST.TELEPHONE:
(714) 554-8888
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:42CENSUS: 36DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Lucy BrimbuelaTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility staff verbally intimidated client while having an evaluation meeting
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff, clients and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that facility staff verbally intimidated client while having an evaluation meeting, the investigation revealed the following: Both staff and Client 1 (C1) confirmed a conversation regarding the client's pending discharge to independent living. C1 indicated displeasure with the discharge and in the course of the conversation stated Staff 1 (S1) made threatening remarks toward the client. Staff 1 denies making threatening remarks towards the client at any time. S1 denies threatening remarks to any client at any time. During the investigation, LPA interviewed staff and additional clients residing at the facility regarding the allegation. Three out of three staff and five out of five clients deny witnessing any threatening remarks or inappropriate conversation with staff at the facility. Based on interviews conducted, CONTINUED ON LIC 9099C DATED 11/21/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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 22-AS-20231106170848
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PALM VILLAGE
FACILITY NUMBER: 306002008
VISIT DATE: 11/21/2023
NARRATIVE
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 LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2