<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:33:00 AM

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
01/21/2025 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20250121122441
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: 111DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:John GarciaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are mismanaging residents' medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint Investigation was conducted on this day regarding the allegation mentioned above by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Interim Administrator John Garcia and Assistant Administrator Kathleen Tamondong

During the course of the investigation, LPA reviewed Medication Administrator Records (MARs) for ten residents and interviewed staff. LPA observed discrepancies in five of ten records. Resident 1’s (R1’s) MAR indicated five routine medications are not currently being administered, and one of the five medications is completely out, and has been without a refill for three days. During today’s inspection, two of four PRN medication for R2 were observed to be without a refill. During review of R2’s medication, during initial complaint investigation conducted on January 28, 2025, three of four PRN medications were observed to be without a refill. Per R3’s MAR, routine medication was not administered on the morning of January 24th and 27th 2025, and the evening of January 25th and 26th, 2025 as it was not signed by staff to indicate it was administered or otherwise. (LIC9099-C)
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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-20250121122441
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: 01/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During their interview, Staff 1 (S1) stated medication had not been administered due to R3 being in the hospital. Upon review of R3’s medication, medication was observed to no longer be in the prescription bubble pack issued by the pharmacy. Upon medication review for R4, LPA observed routine medication was not administered on January 12, 2025, nor on January 19, 2025. R4’s MAR was left blank on January 12, 2025, but was signed off by staff on January 19, 2025, despite medication having not been administered and observed to still be inside the prescription bubble pack issued by the pharmacy. Per R5’s MAR, two routine medications were not administered on January 27, 2025 and five of seven PRN medications were not observed. During their interview, S2 stated medication has been administered and signature had been overlooked by staff. During their interview, S1 indicated five of the seven PRNs for R5 were currently awaiting refill and not available for review.

Based on staff interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20250121122441
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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
HSC
1569.2(c)
1
2
3
4
5
6
7
"Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety or welfare would be endangered.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
IAD stated residents' MARs will be updated to reflect correct information regarding medication administration and medication staff training conducted. IAD stated they will provide LPA with proof via email by POC date.
8
9
10
11
12
13
14
Based on staff interviews and records review, the licensee did not comply with the section cited above as residents' medication is being mismangaged, which poses an immiedate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3