198205024-4-7-2022-28-AS-FFIS-CDG2H7-20220413172415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 04/07/2022
Date Signed: 04/07/2022 10:59:44 AM

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 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:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lorenzona Medina, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of supervision results in resident being assualted on several occasions by another resident.

INVESTIGATION FINDINGS:

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***This Licensing report supersedes the original complaint investigation report created dated 03/24/22. The finding remains the same as in the prior licensing report -Unsubstantiated. ***

On 01/23/20, Licensing Program Analyst (LPA) Tao conducted an initial ten-day visit and met with Administrator/ Licensee, Rodrigo E. Ramos. During visit, LPA interviewed the CEO and Resident #1 and toured the physical plant. LPA also reviewed and obtained copies of the documents listed below in reference to resident #1 (R1) and resident #2 (R2); Physician report; Identification and emergency information; Resident’s appraisal; Resident’s handbooks; Personal rights; Individual service plan; incident report for incident on 1/14/20; Police report receipt / number. LPA obtained copies of the on-job training log of staff #2 (S2), #3 (S3) and #4 (S4).

On 04/15/21, LPA Tao conducted a subsequent visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with Administrator. (-Continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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 3

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: 04/07/2022

NARRATIVE

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***This Licensing report supersedes the original complaint investigation report created dated 03/24/22. The finding remains the same as in the prior licensing report -Unsubstantiated. ***

During the subsequent visit conducted on 04/15/21, LPA interviewed staff #1 through staff #6 and resident #1 through resident #7. LPA obtained Resident roster, Staff roster, incident report dated 01/14/20 and resident #1’s medical report.

On today’s visit, LPA Tao met with Administrator, Lorenzona Medina and CEO, Rodrigo E. Ramos and discussed the complaint investigation findings. The investigation consisted of interviews with staff and residents; review of facility records for R1 an R2, and R1’s medical records.

Regarding allegation: Lack of supervision results in resident being assaulted on several occasions by another resident. It was alleged that R1 was being physically assaulted by R2 on several occasions and staff were not providing care and supervision. Interviews with six (6) out of six (6) staff revealed they were not aware of the incident between R1 & R2 in which R1 was being assaulted by R2 and staff were not aware of a resident being assaulted by another resident. All six (6) staff stated they did not witness or hear any noise from resident’s (R1 & R2) room during the alleged incident. LPA interviewed seven (7) residents, five (5) out of seven (7) residents revealed that they were not aware of an incident between residents in which a resident was being assaulted by another resident and staff did not intervene. LPA interviewed R2 indicated that R2 denied hitting R1 or having an altercation with R1. LPA interviewed R1 indicated that on the morning of 01/14/20, S2 observed R1’s left hand was swollen and asked R1 what happened. R1 reported to S2 that R2 hit R1 with a cane during an argument in the resident’s room. LPA interviewed administrator who indicated that R1 and R2 have been roommates for several years. Administrator stated that an incident between R1 and R2 occurred on 01/14/20, in which staff observed R1 to have a swollen hand, staff had immediately obtained medical treatment for R1. Administrator stated that R1 and R2 had no prior history of having altercations with one another and this was a one-time incident.

(-Continued in LIC 9099 C-)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 04/07/2022

NARRATIVE

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***This Licensing report supersedes the original complaint investigation report created dated 03/24/22. The finding remains the same as in the prior licensing report -Unsubstantiated. ***

The investigation revealed that an incident occurred on 01/14/20 between R1 and R2, in which R1 was sustained injury to left hand and required medical attention. S2 immediately sent R1 for medical treatment. R1 was treated for two fractured fingers in the left hand. Medical staff reported the incident to local law enforcement and R2 was arrested for assaulting R1. Per the review of the special incident report, dated 01/14/20, it indicated that S2 observed R1 had a swollen hand and asked what occurred. R1 informed S2 that R2 hit him with a cane. S2 then sent R1 for medical treatment and R1 was treated for finger fractures of the left hand. Administrator placed R1 and R2 into different rooms on 01/15/20 in order to ensure R1 and R2 safety. Administrator reported the incident report, dated 01/14/20, to Licensing timely.
Based on interviews conducted with staff and residents; records reviewed, including incident report dated 01/14/20; R1’s medical records review, dated 01/15/20; local law enforcement report #20-2887 review, dated 01/15/20, the investigation did not reveal that staff failed to provide adequate care and supervision to R1 and/or R2 and did not reveal that R1 and R2 had a prior history of having altercations with one another. Therefore, this 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.

An exit interview was conducted with Administrator, Lorenzona Medina, and CEO, Rodrigo E. Ramos. A hard copy of this licensing report was provided during today’s visit.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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