<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 04/15/2021
Date Signed: 04/16/2021 02:34:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2020 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20200121173041
FACILITY NAME:HACIENDA GRANDE SENIOR ASSISTED LIVINGFACILITY NUMBER:
198205024
ADMINISTRATOR:MARIANNE A HODELFACILITY TYPE:
740
ADDRESS:1740 GRAND AVENUETELEPHONE:
(562) 597-7753
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:120CENSUS: 46DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rodrigo E. Ramos, Licensee,
Lorenzona Medina, Administrator		TIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision results in resident being assualted on several occasions by another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao conducted a subsequent virtual complaint investigation for the allegation listed above. An initial ten-day visit was conducted on 01/23/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator.
The investigation consisted of interviews with victim, staff, and residents; review of facility records, and Resident’s medical records.

LPA conducted interviews with Staff from Staff #1 through Staff #6 and from Resident #1 through Resident #7. LPA obtained Resident roster, Staff roster, incident report (01/14/20), and Resident #1 medical report.
The investigation revealed: Resident #1(R1) was being assaulted by another client. According to staff interviews, staff acted immediately and reported to Administrator when staff observed R1 had a swollen hand. Administrator investigated the incident and R1 was transported to the hospital for evaluation. Six (6) out of six (6) staff interviewed had denied the allegation. LPA interviewed seven (7) residents and six (6) of them denied the allegation.
(-Continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20200121173041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING
FACILITY NUMBER: 198205024
VISIT DATE: 04/15/2021
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
26
27
28
29
30
31
32
Based on interviews conducted, the statement provided were inconsistent regarding the allegation listed above. There is insufficient evidence to support the allegation that resident was being assaulted by other resident due to lack of supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2