198205024-6-25-2021-11-AS-JJON-C4BSNR-20210625140157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205024
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:02:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HACIENDA GRANDE SENIOR ASSISTED LIVING		FACILITY NUMBER:	198205024
ADMINISTRATOR:	MARIANNE A HODEL		FACILITY TYPE:	740
ADDRESS:	1740 GRAND AVENUE		TELEPHONE:	(562) 597-7753
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY:	120	CENSUS: 44	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Elvie Medina		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/25/21 Licensing Program Analyst/LPA Jade Jordan Conducted an Unannounced Annual Inspection Control visit. LPA was met by facility Administrator Lorenzona Medina, and the purpose of the visit was explained. A physical tour of the facility was taken, and LPA observed a Two story building, which can accommodate 120 capacity. LPA sampled Resident rooms on both floors. The residents bedrooms were inspected for safety, privacy, and comfort. Each room has its own bathroom with fully functioning sinks, toliets, water basins. The rooms are each equipped with an air conditioning unit. There is a signal/call system in each resident apartment, and it is functioning properly. The kitchen was observed for the ability to prepare and serve food. LPA's observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non- perishables. All storage areas for cleaning solutions, toxics, knives, and hazardous items are in a secured cabinet and inaccessible to residents. The facility’s smoke detectors are functioning properly. The fire extinguishers are fully charged and meet regulations. The front ground is well landscaped with a ramp leading up to the entrance, Activity room located on first floor next to entrance. Posters informing residents of their right to call Licensing & The Ombudsman's office are posted prominently on the first floor. LPA Sampled Resident files, and staff files. The outdoor patio area is free of visible hazards and debris. There was no evidence of bodies of water (pool/spa) or security bars or weapons on the premises. A technical Advisory was given for the 1^st floor Hallway, where LPA observed some minor cosmetic scuff, and for the second-floor carpet in which normal wear and tear unraveling’s was observed.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING	FACILITY NUMBER: 198205024
	VISIT DATE: 06/25/2021

NARRATIVE

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The medication room is located on the 2nd floor, and medications are locked and labeled as required.

LPA observed staff wearing masks, Visitor Log /Symptom screening Log, Designated isolation room, required Covid-19,Postings, 30 day supply of PPE and other required documents, including phone numbers are posting as mandated by the DPH and CCLD.

No citations were issued during visit, a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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