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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:32:57 PM

Substantiated


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
07/06/2022 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220706152624
FACILITY NAME:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BARRIENTOS, ELEANORFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:144CENSUS: 114DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Assistant Administrator, Kathleen TamondongTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not adequately supervise resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to deliver findings on a complaint investigation. LPA identified themselves and discussed findings with Assistant Administrator Kathleen Tamondong..
During the course of the investigation LPA Jenifer Tirre interviewed staff and residents as well as obtained pertinent documentation. Resident’s Physicians Report dated 12/7/2021 states R1 has a Dementia diagnosis and is unable to leave the facility unassisted. Staff interviews confirm R1 exited Memory Care wing and exited facility shortly after. Police Records from Fullerton and Fountain Valley Police department confirm on the day resident left facility unattended resident was located in the city of Fountain Valley and taken to Fountain Valley Hospital.

Based on interviews, and records, the department has found, the preponderance of evidence standard has been met, therefore the above allegation Staff did not adequately supervise resident is deemed to be SUBSTANTIATED per California Code of Regulations, (Title 22, Division 6, Chapter 8).
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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
Control Number 22-AS-20220706152624
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 11/08/2022
NARRATIVE
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An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of this report, along with a LIC 811 form, copy of citation and copy of Appeal Rights have been provided to Facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220706152624
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code and Health and Safety Code Section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to submit a detailed written plan on ensuring residents are unable to elope out of facility. Licensee to forward proof to LPA by POC due date.
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Based on interviews conducted and records received Licensee failed to ensure care and supervision were provided to R1. R1 elopped out of the facility on 6/28/22 and was found in another citty This poses an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3