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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:22:13 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
02/01/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240201121336
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: 131DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Erin RehbeinTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff did not provide adequate notice of rate change
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into 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 and resident as well as reviewed and obtained pertinent documentation such as rate increase letter. Regarding the allegation that staff did not provide adequate notice of rate change, the investigation revealed the following: Facility staff indicate scanning a notice of rate change to Resident 1's (R1) responsible party on 11/20/2023 after receiving notification from Community Care Licensing of the SS1 rate change. Facility mailed an additional copy on 12/15/2023 for signature. Responsible party stated not receiving the first notice and receiving the second notice on 12/28/2023. Facility staff stated scanning the first notice directly from facility scanner and not from email. Facility staff indicated no way to access a receipt or dated proof of scan. Administrator reached out to tech support for guidance on how to access a scan receipt. Tech support indicated no receipt or time stamp is available. CONTINUED ON LIC 9099C DATED 02/08/2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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-20240201121336
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: 02/08/2024
NARRATIVE
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Based on interviews conducted and record review, 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: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2