Facility Evaluation Report

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.