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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880511
Report Date: 06/27/2025
Date Signed: 06/27/2025 04:32:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2021 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 18-AS-20210218171854
FACILITY NAME:PALMS AT LA QUINTA, THEFACILITY NUMBER:
331880511
ADMINISTRATOR:PATRICK MCADOO-MORTONFACILITY TYPE:
740
ADDRESS:45160 SEELY DRIVETELEPHONE:
(760) 345-5353
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:120CENSUS: 101DATE:
06/27/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Roland Gandy, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 06/27/2025, Licensing Program Analysts (LPAs) Becky Mann and Edith Conchas conducted an unannounced visit to the facility to deliver complaint investigation findings for the above allegation. After introducing and identifying self, LPA met with Roland Gandy, Executive Director to discuss the findings.

On February 18, 2021, the Department received a complaint with multiple allegations including allegation of personal rights violation resulting in Resident #1 (R1) sustaining and injury (fracture). The Department investigation consisted of review of facility and medical records, observations, and interviews with pertinent individuals.

Investigation revealed that around 5:45 pm on February 16, 2021, R1 experienced a fall in facility apartment. According to information received from R1 and other individuals, R1 was changing their shirt when it got caught on their head, causing R1 to lose balance and fall backwards.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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 5
Control Number 18-AS-20210218171854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PALMS AT LA QUINTA, THE
FACILITY NUMBER: 331880511
VISIT DATE: 06/27/2025
NARRATIVE
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 In addition, it was reported that during the incident, R1 tripped over a case of water located near their closet, where R1 was changing. Medical services were contacted and R1 went to local hospital. Medical records revealed that R1 was diagnosed with a left hip fracture.

Interviews confirmed that around 9:00 am on February 16, 2021, R1 received a delivery of two cases of bottled water which were taken to R1 room. These cases were observed by staff on date of incident. In addition, at least one staff reported that regarding R1, it was not uncommon for cases of water to be placed in front of closet door in R1 room. Department investigation further revealed that at least four staff entered R1 room on February 16, 2021, following delivery of cases, but the cases were not moved from placement on floor near closet where R1 fell. The cases remained in this area utilized by R1.

According to interviews and facility records, R1 was visually impaired (legally blind) and utilized walker for mobility. Records also revealed that R1 required assistance with bathing, dressing (assistance with putting pants on), and toileting (some assistance). R1 Admission agreement includes those basic services such as safe and healthful living environment for all residents…will be provided. The preponderance of evidence found during investigation supports that facility staff did not provide accommodations for a safe and healthful environment for R1. On February 16, 2021, for an unknown period of time, at least one case of water was left near R1 closet. This case created a tripping hazard to R1, who was legally blind. As a result, R1 sustained a fracture as a result of experiencing a fall and tripping over the case of water.

The allegation, Licensee did not ensure safe accommodations resulting in R1 sustaining an injury is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.

In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Roland Gandy, Executive Director.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210218171854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PALMS AT LA QUINTA, THE
FACILITY NUMBER: 331880511
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2025
Section Cited
CCR
87468.1(a)(2)
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Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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The facility shall follow procedures when deliveries are made to residents. A Plan of Correction (POC) statement of understanding will be provided to LPA by POC due date.
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Based on record review and interviews, the facility failed to ensure the safety of
Resident #1(R1). On 2/16/21 R1 fell over a case of water that was left on the floor near the closet, which resulted in a fracture. This is 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.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2021 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 18-AS-20210218171854

FACILITY NAME:PALMS AT LA QUINTA, THEFACILITY NUMBER:
331880511
ADMINISTRATOR:PATRICK MCADOO-MORTONFACILITY TYPE:
740
ADDRESS:45160 SEELY DRIVETELEPHONE:
(760) 345-5353
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:120CENSUS: 101DATE:
06/27/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Roland Gandy, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs
Staff are not administering medication as prescribed
Facility is unsanitary
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Becky Mann and Edith Conchas conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Roland Gandy, Executive Director and explained the purpose of today's visit. The investigation consisted of LPAs observations, pertinent document reviews, and interviews with staff and residents.

The allegation is staff are not meeting resident's hygiene needs. Four (4) staff interviewed stated that they do meet resident's hygiene needs. Seven (7) residents interviewed stated that staff does meet resident's hygiene needs. Staff assist residents with their showers when needed. Based on the interviews with the residents, staff are very helpful and takes care of the resident's hygiene needs.

The allegation that staff are not administering medication as prescribed. Two (2) Medtechs interviewed stated that they are administering medication as prescribed. Based on LPAs observations and record reviews in the Med Room, the medications are being administered within the timeframe as prescribed by physicians.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210218171854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PALMS AT LA QUINTA, THE
FACILITY NUMBER: 331880511
VISIT DATE: 06/27/2025
NARRATIVE
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The allegation that facility is unsanitary. LPAs toured the facility with Roland Gandy, Executive Director. Based on LPAs observations the facility is clean and sanitary. Staff does maintain the facility by keeping up with the cleaning at all times.

Based on evidence obtained during the investigation, the above allegations are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed, and a copy was provided to Roland Gandy, Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5