306006071-7-5-2022-22-AS-AORZ-CJANYD-20220915105231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:24:56 PM

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
04/19/2022 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220419154601

FACILITY NAME:	PALMS RETIREMENT CENTER		FACILITY NUMBER:	306006071
ADMINISTRATOR:	BARRIENTOS, ELEANOR		FACILITY TYPE:	740
ADDRESS:	312 N ROOSEVELT AVE		TELEPHONE:	(626) 353-4710
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY:	144	CENSUS: 110	DATE:	07/05/2022
		UNANNOUNCED	TIME BEGAN:	02:48 PM
MET WITH:	Business Office Coordinator Kathleen Tamondong		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents engaged in an altercation while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to the facility today and met with Business Office Coordinator Kathleen Tamondong for the purpose of delivering the findings for above allegations.

During the course of the investigation, LPA toured the facility, interviewed staff and interviewed residents as well as obtained pertinent documentation. Based on the information received from interviews, the lack of information regarding the incident, and lack of corroborating witnesses to the incident the department has found the allegation residents engaged in altercation while in care deemed UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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