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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/16/2021
Date Signed: 04/26/2021 11:39:26 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/08/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210208110203
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 107DATE:
04/16/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:ADMINISTRATOR LESLY FIGUEROATIME COMPLETED:
09:56 AM
ALLEGATION(S):
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Staff did not assist a resident with hygiene needs
INVESTIGATION FINDINGS:
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On 04/15/2021 around 10:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Lesly Figueroa.

The Investigation consisted of the following: On 02/16/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 3/17/2021 LPA obtained copies of Staff and Resident rosters, physicians report. On 2/23/2021 LPA Calderon interviewed reporting party (R1). On 3/12/2021 LPA Calderon interviewed S2-S6 and on 3/12/2021 LPA Calderon interviewed R1- R10. On 4/15/2021 LPA Calderon interviewed S8 for complaint.

The investigation revealed the following:

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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 11-AS-20210208110203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 04/16/2021
NARRATIVE
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Allegation: Staff did not assist a resident with hygiene needs.
It is alleged facility staff are changing incontinent residents diapers but is not changing the sheets when they are soiled. On 4/15/21, LPM Hammond and LPA Calderon interviewed Administrator Lesly Figueroa regarding the allegation, she stated she is aware that caregivers are changing incontinent residents diapers but not changing the linens when they are soiled stating that is the responsibility of the housekeepers. The Administrator stated she has explained she informed caregivers it is their responsibility to change the sheets not the housekeepers. On 3/12/2021 LPA Calderon interviewed R2-R10 that stated they were not aware of any issues with hygiene needs not being met. 03/12/2021 LPA Calderon interviewed S2- S6 and staff denied the allegation. On 03/17/2021, LPA received and reviewed physicians report for R1 and it indicates R1 needed assistance with incontinence care. LPA was unable to interview R1 as she is deceased.. On 04/15/2021 LPM Hammond and LPA Calderon interviewed S7 and S7 stated that there are major training issues regarding hygiene needs for all residents. On 4/15/21, LPM Hammond and LPA Calderon interviewed S8 regarding the allegation, S8 stated while on shift when R1s Hospice Nurse came to the facility and complained R1s diaper was clean but R1s sheets were soiled with feces and urine and had not been changed. S8 stated the staff went and changed the residents sheets.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator Lesly Figueroa, and a hard copy was provided via email for records
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210208110203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87625(B)(2)(3)
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87625 Managed Incontinence (b) In addition to Section 87611...(2) Ensuring that incontinent residents are checked...(3) Ensuring that incontinent residents are kept clean and dry...This requirement is not met as evidenced by:
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During inspection, administrator confirmed more incontinence training needs to be done for staff and administrator will need to provide LPA Calderon training infomation and sign in sheet.
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Based on interviews LPA Calderon confirm that caregivers are not changing bed sheets for residents beds when needed which poses an immediate health,risk to persons 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: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3