Facility Evaluation Report

On April 22, 2025, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is reference with complaint #11-AS-20240215081652 and the Case Management visit on August 30, 2024, with Palmcrest Grand Residence.

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 that resident #2 (R2) was never evicted from the facility and informed that (R2’s) family representative (R2) was able to return to the facility. Information was provided to (IB) Investigator Sandoval, who claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the incident of 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 no reports of aggressive behavior by any 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.