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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 02/20/2026
Date Signed: 02/20/2026 10:38:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250606143306
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:GOMEZ, VERONICAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 145DATE:
02/20/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Veronica Gomez/Executive DirectorTIME COMPLETED:
10:37 AM
ALLEGATION(S):
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Staff neglect resulted in a resident being hospitalized.
Staff did not address a resident's change in medical condition.
INVESTIGATION FINDINGS:
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On 2/20/2026 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Veronica Gomez/ Executive Director. LPA explained the purpose of this visit.


Investigation Consisted of the department conducted the following interviews: Administrator Interview (A#1), Resident Interviews (R#1), and Facility Staff Interviews (S#1-S#2). The department gathered the following documentation: Copy of (R#1)’s hospital records dated: 2/4/25, and 1/19/2025, copy of (R#1)’s Appraisal or LIC 603A dated:6/1/25, and copy of (R#1)’s physician report or LIC 602A dated:5/23/24.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
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 6
Control Number 11-AS-20250606143306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/20/2026
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff did not address a resident's change in medical condition

The details of this complaint alleges that the facility failed to re-assess (R#1) after multiple falls.

On October 30, 2025, the department conducted a review of medical records and found the following:

On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. The hospital performed imaging tests that revealed no fractures. (R#1) was discharged the same day.

On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment and discharged February 7,2025.

On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital and was discharged the same day.

On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. (R#1) was discharged the same day with documentation indicating orthopedic surgery would be scheduled. On June 5, 2025, (R#1) returned to the hospital due to injury-related pain.

On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls.

On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250606143306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/20/2026
NARRATIVE
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On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls.

On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls.

On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250606143306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/20/2026
NARRATIVE
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On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs.

Allegation: Staff neglect resulted in a resident being hospitalized

The details of the complaint allege that facility staff failed to appropriately respond to changes in condition for (R#1), following multiple falls.

On October 30, 2025, the department conducted a review of medical records and found the following:

On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom.

On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment.

On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital.

On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20250606143306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
02/23/2026
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...
This requirement was not met as evidence by:
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The licensee will adhere to Title 22 regulations at all times. As a plan of correction, the facility will follow a new system that will allow facility staff record chek-ins of the residents. A proof of this correction will be sent to LPA Iniguez via email.
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Based on interviews and record review, the licensee failed to ensure that the facility did not complete (R#1)’s Needs and Services Plan each time they return from the hospital and there was not written documentation on the treatment plan changes after each incident. This poses a potential health and safety risk to residents in care.
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Under Appeal
Type A
02/23/2026
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (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 evidence by:
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The licensee will adhere to Title 22 regulations at all times. As a plan of correction, the facility will follow a new system that will allow facility staff record chek-ins of the residents. A proof of this correction will be sent to LPA Iniguez via email.
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Based on interviews and record review, the licensee failed to ensure that (R#1) was provided with the necessary care and services to prevent them from falling a few times. This poses a potential 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20250606143306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/20/2026
NARRATIVE
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During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s).

Therefore, the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

*Immediate Civil Penalty issued*

At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident.

An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6