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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 03/30/2023
Date Signed: 04/21/2023 10:42:50 AM

Document Has Been Signed on 04/21/2023 10:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 122DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Administrator- Peggy ClarkTIME COMPLETED:
04:30 PM
NARRATIVE
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 On 03/30/23, Licensing Program Analyst (LPA) Lizeth Villegas and licensing program manager (LPM) Janae Hammond conducted an unannounced annual required visit using the CARE Inspection Tool. LPA and LPM met with the Administrator Peggy Clark and assistant administrator Veronica Gomez as the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents of which 10 maybe bedridden ages 60 and over. The facility has an approved Hospice Waiver for 10 residents.

The facility is a large two-story building located in a residential neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common area, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with the switch board in the reception area and is operational from all resident living units.

LPA and LPM conducted record reviews of (11) residents records, (10) staff records all which were complete. LPA and LPM reviewed (10) Client Medication Administration Records. The facility disaster plan and the last drill was conducted on Monday 03/27/23. The facility disaster plan is current and in compliance with Title 22regulations at the time of visit.

LPA and LPM checked resident units, mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to residents. The water temperature properly

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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Document Has Been Signed on 04/21/2023 10:42 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/30/2023 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee failed to ensure the current administrator on record 9Peggy Clark) has received their recertification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator statd that licensee will appoint a certified administrator by POC due date.Licensee shall submit change of administrator packet to licensing by POC due date.
Deficiency Dismissed
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities

Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee failed to comply with the section cited above as room 424 there was a lock on the outside of the bathroom door preventing resident from accessing the bathroom which poses/posed a personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator removed lock from the door at the time of the visit, this citation is CLEARED AT TIME OF VSIT.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2023 10:42 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/30/2023 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87628(a)

87628-Diabetes
The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as facility staff is assisting residents with glucose testing and insulin injections. Facility staff are not appropriately skilled professionals
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee to submit a plan outlining the steps the facility will take to ensure compliace with Title 22 regulations 87628 Diabetes by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 03/30/2023
NARRATIVE
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measured between 105F-120F.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit the following deficiencies were observed;

During the review of Administrators Peggy Clark record review, it was observed that the Administrators certificate expired on 10/18/2020. LPA and LPM asked Administrator for a current Administrator certificate and Administrator reported she is currently taking her continued education units and has not recertified at this time.

During the review of Medication Administration Records for resident number 1 it is observed that resident is diabetic and is receiving glucose checks and is receiving insulin injections. LPA and LPM inquired who is responsible for checking resident number 1 glucose and insulin injections and were informed that staff is responsible for checking resident’s glucose and staff assist residents with hand over hand insulin injection. LPA and LPM reviewed resident number 1 physician report which indicates resident is not able to administer glucose testing nor insulin injections. The administrator informed LPA and LPM that there are no appropriate skilled professionals working at the facility.

Deficiencies cited under California code of regulations title 22, division 6, chapter 8 are being cited on attached LIC 809 D.

Exit interview conducted with Administrator Peggy Clark, appeals rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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