198205024-5-27-2022-11-AS-MVAO-CF6RN7-20220607130951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 05/26/2022
Date Signed: 05/27/2022 07:03:09 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, 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
05/23/2022 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220523130359

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: 45	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Rodrigo Ramos		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Resident is being threatened by another resident in care

INVESTIGATION FINDINGS:

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On 5/26/22 at 9:44am., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Rodrigo Ramos. LPA explained to Mr. Ramos the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 5/26/22 with (5) staff members (6) residents. In addition, on 5/26/22, LPA and Mr. Ramos conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Hacienda Grande Senior Assisted Living Administrator Ramos: LIC 500-staff roster, client roster, Internal staff incident reports for May 2022, House Rules, R1 and R2 Physician Report, R1 and R2 Assessment Service Plan, and R1 and R2 Case Notes.

Report continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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-20220523130359

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: 05/26/2022

NARRATIVE

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Investigation

Allegation: Resident is being threatened by another resident in care.

The investigation revealed, per LPA interviews, with (5) staff members, (6) residents from the Hacienda Grande Senior Assisted living facility, and also review of facility documents, that resident is not being threatened by another resident in care. S1 informed the LPA, that all the residents in the facility get along, and that S1 has not reviewed reports from staff or residents, that there are any issues with the residents in the facility. S1 also informed the LPA, that S1 and S2, address all issues or concern, that are reported to them, regarding residents or staff. S2 also stated that S2 is in contact with the staff in the facility, and all daily incidences and occurrences are reported to S1 and S2, so that they may follow up and resolve. Furthermore, S1 and S2 informed the LPA, that R1 and R2 have never had any interaction in the facility. And also, S1 and S2 have never received reports, that R2 has intimidated a resident in the facility. In addition, S1 informed the LPA, that R2, does not interact with residents in the facility, and prefers to be alone. To date, R2 has been compliant with all facility house rules, and does not bother anyone. The LPA also interviewed 5 facility staff personnel, and 5 of the 5 staff personnel interviewed, informed the LPA that they have not witnessed or received reports from resident, staff or family, that a resident is threatened by another resident in the facility. In addition, the LPA interviewed (6) residents, and 5 of 6 residents interviewed, informed the LPA, that the residents in the facility get along, and also that they do not feel threatened by a resident in the facility. Also, 6 of 6 residents interviewed, informed the LPA, that the staff at the facility help them and are available to them when needed.

Based on information gathered, the LPA did not find sufficient evidence to support allegation " Resident is being threatened by another resident in care ”

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. No citations issued. An exit interview was conducted with Rodrigo Ramos, Administrator, and a hard copy of a LIC 9099 was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

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