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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:09:05 PM

Document Has Been Signed on 03/28/2022 01:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:PEGGY CLARKFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 262CENSUS: 106DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR PEGGY CLARKTIME COMPLETED:
02:00 PM
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On 03/28/2022 around 10:00am Licensing Program Analysts (LPA) Jose Calderon conducted an unannounced Required 1-year inspection. LPA Calderon met with Administrator Peggy Clark and discussed the purpose for today’s visit. The facility is a 2-story building, that is licensed for a capacity of 262 in which a total of 10 can be bedridden. There is currently a total of 106 residents (38 in the Memory Care Unit).

LPA Calderon toured the entire physical plant which includes: reception desk, mail box area, administrative offices business offices, recreation area, beauty salon, utility closets, storage room(cleaning solutions and toxins were locked and inaccessible to residents), linen closets, 5 television areas(2 in memory care), medication room, kitchen, dining room, lounge/pool table area, restrooms, laundry room, and inspected randomly selected 3 bedrooms on the first and 3 second floor as well as 4 rooms in the memory care unit. All bedrooms were observed, pull cords in the bathrooms and bedrooms for emergency assistance were tested. Bathrooms contain grab bars, non-skid mats and are clean and operable. The 7-day supply of perishable and 7-day non-perishable food was observed to be complying. LPA Calderon did observe expired nonperishable foods being stored. Administrator and lead cook advised that this would be taken care of today. The water temperature was tested throughout the facility and averaged between 107.1- and 112.8-degrees F.

LPA Caldron reviewed 4 resident records and observed that residents in rooms 114, 119, 129 and 239 did not have any issues with their Physician's reports and Appraisal / Needs and Service plans.

LPA Calderon conducted a tour of the facility randomly inspected selected bedrooms 114, 119, 129, 239, 417, 419 and 421 observed that: in rooms 114, 119, 129 the non-slip shower tape needed to be replaced. In room 239 the mattress needed to be turned over per the resident. In room 419 the shower door handle needed to be replaced. Per the administrator all issues would be repaired today.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/28/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed under California code of regulation title 22, division 6, chapter 8.

Exit interview held. A copy of the report was provided to Administrator Peggy Clark.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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