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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:38:33 PM

Substantiated


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
02/26/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20210226154939
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: 44DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Elvie Medina/ Rodrigo RamosTIME COMPLETED:
03:38 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
Facility retained a resident with a prohibited health condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jade Jordan made an unannounced visit to the facility and was greeted by Administrator (Lorenzona “Elvie” Medina). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

An Initial 10-Day virtual visit was conducted by LPA Jade Jordan on 03/01/21 (via telephonically) with Administrator due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

During the virtual, video conference call with Administrator Medina, LPA Jordan conducted a virtual tour of the physical plant of the facility. LPA interviewed five (5) residents in care and requested pertinent documentation (Physician’s Report, Admissions Agreement, Emergency Contact Info, and Home Health Agency notes) for Resident #1. A separate investigation was conducted by Department of Social Service Investigator Eddie Hector which included review of medical records, interview with facility staff and medical services staff.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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 5
Control Number 11-AS-20210226154939
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: 04/08/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that Resident #1 (Referred to as R1) was a resident at the facility and was receiving home health care services. R1 was admitted to the hospital on 02/25/21 for multiple pressure injuries: Left lateral knee (Stage 2); Left foot (purple); Left hip (unstageable); Right heel (purple); Right lateral malious (purple); Right lateral foot (purple-deep pressure injury); Right medial foot (marron); Right hip (unstageable); Left lateral calf (stage 2). On 02/22/21 R1’s diagnosis elevated to a right hip pressure ulcer – Stage 4 (measured: 5x5.5 x 0.8 cm) with moderate purulent drainage with foul smell; left hip (measured: 7 x 6.5 x 0 cm) covered with yellow and gray slough (100% with moderate purulent drainage and foul smell). Right hip pressure ulcer Stage 4 (measured: 5cm x 5.5cm x 0.8cm) with 60% red wound bed and 40% yellow slough. Left hip pressure ulcer (unstageable) – measured: 7cm x 6.5cm x 0cm covered with 100% yellowish slough (now, almost double in size) with foul smell. Facility staff were assisted weekly by Home Health Agency (HHA) skilled nurse who worked together to provide care for R1. In addition, weekly training was being provided to facility staff as to the needs of R1. Facility staff applied first aid and would reposition R1 every 2 hours to prevent further injury. The care plan explains the care provided to R1 by the HHA skilled nurse and facility staff which was consistent with documentation in R1’s care plan instructions. Facility staff reported that R1 would regularly remove its diaper and scratch its wounds and was unwilling to allow the HHA skilled nurse to perform wound care.

Based on the evidence gathered, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be SUBSTANTIATED.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20210226154939
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: 04/08/2022
NARRATIVE
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Regarding Allegation #2: this investigation revealed that Resident #1 (Referred to as R1) was receiving care by a Home Health Agency (HHA) while at the facility. On 02/22/21 R1’s diagnosis elevated to a right hip pressure ulcer – Stage 4 (measured: 5x5.5 x 0.8 cm) with moderate purulent drainage with foul smell; left hip (measured: 7 x 6.5 x 0 cm) covered with yellow and gray slough (100% with moderate purulent drainage and foul smell). HHA skilled nurse documented R1’s wounds were getting worse and that R1 continued to deteriorate. On 02/24/21, R1’s wound culture obtained, both hips and documented: Left hip – 100% stricken foul, pungent odor wound. Resident has pressure ulcers – Stage 2. Deep tissue injury at right hip and inner knee with dry scab. HHA skilled nurse recommended hospitalization for wound debridement. Right hip pressure ulcer Stage 4 (measured: 5cm x 5.5cm x 0.8cm) with 60% red wound bed and 40% yellow slough. Left hip pressure ulcer (unstageable) – measured: 7cm x 6.5cm x 0cm covered with 100% yellowish slough (now, almost double in size) with foul smell. HHA skilled nurse documented Resident was referred to higher level of care. Resident needs total care. On 02/25/21, R1 was hospitalized and diagnosed with multiple pressure injuries: Left lateral knee (Stage 2); Left foot (purple); Left hip (unstageable); Right heel (purple); Right lateral malious (purple); Right lateral foot (purple-deep pressure injury); Right medial foot (marron); Right hip (Stage 4); Left lateral calf (Stage 2).

Based on medical information provided by the Home Health Agency’s skilled nurses (between 01/03/21 to 02/25/21) to Administrator and facility staff, R1 was diagnosed with unstageable and Stage 4 dermal ulcers on 02/22/21. R1’s dermal ulcers required a higher level of care than what facility staff were able to do or provide. Administrator Medina was required to immediately transfer R1 at the point, but failed to do so. Based on the evidence gathered, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Facility retained a resident with a prohibited health condition is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency observed and citation issued (ref. LIC 9099D). Civil penalty assessed.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210226154939
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: 04/08/2022
NARRATIVE
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At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator ((Lorenzona “Elvie” Medina).

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210226154939
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions: Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers).
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The administrator shall read Title 22, Section "Prohibited Health Conditions", send a written statement to CCL by the POC date that she will ensure to stay in constant communication with the medical professional and if the resident's medical condition elevate; meaning they require a higher level of care, they will ensure the resident is relocated to a SNF or hospital, the relocation will take place immediately. Because the administrator retained R1 as a resident at the facility for several months after the Home Health Agency skilled nurse stated a higher level of care due to total care, civil penalties are assessed in the amount of: $000.00 for retaining Resident #1 for several months with a prohibited health condition. The plan is due to the CCLD/El Segundo ASC Office by POC due date.
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The standard of evidence was not met: based on the evidence provided, R1 was diagnosed with unstageable and Stage 4 dermal ulcers on 02/22/21 and 02/24/21 and referred to a higher level of care due to requiring total care.
This poses an immediate health, safety and personal rights risk to residents in care
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Type A
04/11/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. Licensee failed to observe or conduct an assessment of Resident #1’s level of care during which time the resident was receiving home health care services while at the facility from 01/26/21 thru 02/25/21. On 02/22/21,
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Administrator will review Title 22 Regulations, Section 87466 and submit a detailed written plan on how the facility will document and address changes in resident conditions. The plan is due to the CCLD/El Segundo ASC Office by POC date of 04/11/22.
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 Resident #1 was diagnosed with a “right hip pressure ulcer – Stage 4” – measured: 5x5.5 x 0.8 cm. On 02/24/21, HHA Registered Nurse recommended R1 be referred to a higher level of care; as the resident required total care. On 02/25/21, R1 was transferred to Long Beach Memorial Medical Center for wound debridement. This poses an immediate health, safety, personal rights risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
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