198205024-6-13-2022-11-AS-MVAO-CFFV5H-20220616160758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 05/19/2021
Date Signed: 06/13/2022 11:05:54 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
01/04/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210104094959

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: 47	DATE:	05/19/2021
		UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Elvie Medina		TIME COMPLETED:	03:37 PM

ALLEGATION(S):

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9

Resident has sustained multiple unwitnessed falls at the facility resulting in hospitalization

INVESTIGATION FINDINGS:

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****This is an Amended Report of Complaint Intiated 01/12/21; Due to Corona Virus 19, the complaint investigation was conducted virtually, the findings of this report has not changed, and were delivered 05-19-21 to Administrator Elivie Medina*******
Investigation Consisted of : On 01/12//21 Resident Interviews, Staff Interviews, Record Review of Resident Roster, incident reports for the month of Dec 2020 related to falls, were conducted.
Regarding allegation: Resident Sustained Multiple Unwitnessed falls at facility resulting in hospitalization
It was alleged that Resident had multiple unwitnessed falls, resulting in hospitalization. R1 stated that they had fallen out of their wheelchair, due to one leg being shorter. Currently awaiting a proper sized wheelchair. Interviews conducted with administrator revealed that R1 has issues with Methamphetamines, which has attributed to unwitnessed falls in the last month. Interviews conducted with R1 admits to drug use at the facility. Interviews conducted with Residents 1-4 indicated they have no issues with falls. Based on interviews, Record Review and observation the Department finds “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An Exit interview conducted Copy of this report provided no citations issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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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