198205024-5-20-2021-11-AS-MVAO-C6ESDT-20210831134741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:52:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2020 and conducted by Evaluator Erik Brown

COMPLAINT CONTROL NUMBER: 11-AS-20201215141753

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:	05/20/2021
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Elvie Medina, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Residents do not have access to water
Residents are isolated in their rooms

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced subsequent complaint visit to this facility. Upon arrival, LPA was met by Administrator Elvie Medina. LPA explained the purpose of today’s visit.

During the initial virtual visit on 12/16/2020, LPA Brown conducted a FaceTime tour of the facility. LPA Brown requested a copy of the staff and resident roster.

During the visit on 5/6/2021, LPA interviewed Residents #1-4 (R1-4) and Staff #1-3 (S1-3) regarding the complaint allegations.

During today’s visit LPA conducted a physical tour of the facility and observed pitchers of water inside of residents’ rooms. LPA observed residents eating at a social distance in the dining room. LPA interviewed staff #4-5 and Residents #5-6 regarding the complaint allegations.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20201215141753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/20/2021

NARRATIVE

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Based on interviews with resident and staff, there does not appear to be an issue with residents not being able to get water when they want it. Residents also generally stated that they were either not isolated or isolated for their own protection against Covid-19.

Based on LPA Brown’s observations and the interviews that were conducted, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with Administrator Elvie Medina and a copy of this report was provided.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC9099 (FAS) - (06/04)

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