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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 04/03/2024
Date Signed: 04/03/2024 10:55:34 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
03/25/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240325145159
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: 112DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Erin RehbeinTIME COMPLETED:
11:17 AM
ALLEGATION(S):
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Facility is refusing to accept the resident back to the facility
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 interviewed staff and resident as well as reviewed and obtained pertinent documentation such as hospital discharge paperwork. Regarding the allegation that facility is refusing to accept the resident back to the facility, the investigation revealed the following: Resident 1 (R1) was sent out to to Chapman Global Medical Center on 03/15/2024 to be evaluated per physician. On 03/25/2024, Administrator assessed the resident and was concerned the resident was not ready to be released back to the facility due to ongoing behavioral issues. However, Administrator stated receiving the resident back into the facility on 03/26/2024 and accepted the hospital's discharge assessment. Administrator denies refusing to take the resident back to the facility but confirms requesting additional treatment time from hospital for the resident. Resident confirms hospitalization as well as a return to the facility with no issues returning. Hospital discharge CONT ON LIC 9099C DATED 04/03/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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-20240325145159
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: 04/03/2024
NARRATIVE
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paperwork confirms resident was discharged back to facility on 03/26/2024. Based on interviews conducted, 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: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2