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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 05/01/2025
Date Signed: 05/01/2025 04:02:49 PM

Document Has Been Signed on 05/01/2025 04:02 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR/
DIRECTOR:		GOMEZ, VERONICAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 262CENSUS: 142DATE:
05/01/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Peggy ClarkTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On May 1, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced Case Management Continuation visit using the CARE Inspection Tool to continue the annual required visit started on April 23, 2025. LPA Lee met with the Co-Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 142. Facility's Annual fees are current.

Physical Plant/Structure The facility is a large, two-story, building located in a commercial 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 areas, 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 a switch board located in the reception area and is operational from all residential living units.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
VISIT DATE: 05/01/2025
NARRATIVE
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File Review: LPA reviewed (7) resident files and found that ( 7 ) out of ( 7 ) had the required documents. LPA reviewed (7) staff file and the Administrator file and found that (6 ) out ( 7 ) had the required documents, training, and certifications. LPA found that The facility Administrator's certification expired. Administrator is in process of completing the required course work to recertify.

Medications: LPA observed all centrally stored medications secured in a locked med cart in the locked medication room and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medication for (7) residents. LPA observed ( 7 ) out of ( 7 ) resident’s medication were properly maintained and are consistent with properly documented records.

LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area.

During today’s visit LPA cited Title 22 Division 6 chapter 8 Article 7 for 1 deficiency. See 809D.

An exit interview was conducted with Administrator Veronica Gomez, and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2025 04:02 PM - It Cannot Be Edited


Created By: Deborah Lee On 05/01/2025 at 03:33 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above as the Administrator of record has not met the recertification requirements in Section 87407. Administrator has started the classes but has not yet completed the course work to fulfull the recertification requirements, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Administrator Veronica Gomez plans to complete her course work by POC date of 5/15/25. Once completed, the administrator to forward proof of completion to LPA: Deborah.Lee@dss.ca.gov.
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.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Deborah Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


LIC809 (FAS) - (06/04)
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