Inspection visit

Incident investigationAugust 30, 2024

PALMCREST GRAND RESIDENCELicense 1986020693 citations on this visit

3 citations recorded

Inspector’s narrative

What the inspector wrote

On 08/30/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #1 (A1) Veronica Gomez and Assistant Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is in reference to a complaint about Palmcrest Grand Residence Complaint Number 11-AS-20240215081652. During the investigation conducted by California Department of Social Services (CDSS) Investigation Bureau (IB) investigator Sonia Sandoval, it revealed that (A1) withheld information. (A1) stated resident #2 (R2) was never evicted from the facility and informed (R2’s) family representative (R2) was able to return to the facility. Information provided to (IB) Investigator Sandoval claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the of incident 02/02/24. In addition, (A1) stated resident #1 (R1’s) family representative was immediately notified of the condition (R1) was found in abdominal pain. Nonetheless, (R1’s) family representative claimed notification of (R1’s) condition was received after 1300 hours (R1) was discovered by staff of abdominal pain at 0700 hours. (R1’s) family representative was not informed of the additional symptoms (R1) exhibited which included vomiting, diarrhea, and bloody discharge. (A1) provided wrongful removal of resident #2 (R2). (A1) indicated (R2) exhibited aggressive behavioral outbursts and was deemed a safety concern. There were no reports of aggressive behavior by any of the staff present during the incident on 02/02/24. In addition, (R2’s) family representative was notified after (R2) had been transported to the VA hospital that (R2) was not welcome to return to the facility and was not provided an Eviction Notice. The investigation revealed that (A1) obstructed the investigation. Facility staff disclosed fear of retaliation by (A1) and stated (A1) treated them differently for cooperating with IB Investigators. (Evaluation Report continues LIC 809-C) Information gathered indicated when law enforcement went to the facility, (A1) alerted the staff and instructed the staff not to say anything as there was no proof anything had occurred on the incident 02/02/24. (A1) stated to have not reported the incident to law enforcement because (A1) did not observe any signs of an assault. Despite this, (A1) stated to the Long Beach Police Department (LBPD) Detective (R2) had been removed and was not allowed back into the facility due to the incident. Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (A1) failed to carry out the responsibilities and duties of an administrator by withholding information, wrongful removal of residents, and obstruction of an investigation. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Veronica Gomez, Administrator, and a hard copy of the report along with appeal rights.

Citations

5 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(a)(B)(D)Type B
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with incident resident #1 and #2. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety or personal rights risk to persons in care.
87466Type B
87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and socialfunctioning... appropriate assistance is provided when such observation reveals unmet needs. When changes such as... deterioration... a physical health condition is observed, resident's responsibleperson...the licensee shall ensure that such changes...brought to the attention of the resident's physician... This requirement is not met as evidenced by: Facility staff had knowledge of (R1’s) health condition with UTI associated with severe abdominal pains, and failed to seek medical attention in a timely manner. This violation poses a potential health, safety or personal rights risk to persons in care.
87224(b)(c)Type B
87224 – Eviction Procedures (b) The licensee may, grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility. (c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement is not met as evidenced by:Based on interviews by IB, (A1) wrongfully evicted (R2) by transporting to VA hospital and denied accessed to return to the facility. This violation poses a potential health, safety or personal rights risk to persons in care.
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87405(b)(1)(2)(5)Type B
87405 Administrator – Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (d) The administrator shall have the qualifications..(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by:Based on interviews by IB, (A1) failed to carry out the policies and ability to conform to the applicable laws, rules and regulations. This violation poses a potential health, safety or personal rights risk to persons in care.
87413(3)Type B
87413(3) Personnel – Operations(3) The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice.This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This violation poses a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 30, 2024 inspection of PALMCREST GRAND RESIDENCE?

This was a other inspection of PALMCREST GRAND RESIDENCE on August 30, 2024. 3 citations were issued: 3 Type B.

Were any citations issued to PALMCREST GRAND RESIDENCE on August 30, 2024?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: "87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Incident investigation·August 30, 2024