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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:42:31 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/06/2023 and conducted by Evaluator Lizeth Villegas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230906083302
FACILITY NAME:HACIENDA GRANDE SENIOR ASSISTED LIVINGFACILITY NUMBER:
198205024
ADMINISTRATOR:LORENZONA ELVIE MEDINAFACILITY TYPE:
740
ADDRESS:1740 GRAND AVENUETELEPHONE:
(562) 597-7753
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:120CENSUS: 47DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Lorenzona MedinaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to staff neglect resident developed a pressure injury while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/07/23 at 12:00pm Licensing program analyst (LPA) Villegas and Licesing program manager (LPM) Hammond initiated a complaint investigation regarding the above allegations. LPA and LPM met with Administrator Lorenzona Medina as the purpose of the visit was explained.

During todays visit LPA and LPM obtained copies of resident roster and staff roster, toured the physical plant and conducted an interview with Administrator/Licensee Rodrigo Ramos (A1).

The details of the complaint allegation do not match information recevied during investigation. LPA and LPM conducted interview with Administrator/Licensee Rodrigo Ramos to inquire if Resident 1 (R1) ever resided at facility, Administrator stated there has not been a resident by the name at the facility. LPA and LPM asked administrator if there is or has been any Registered nurse employeed by the name of "Manny", Administrator reported there was a Manny employed but was a cook. LPA and LPM reviewed resident roster and did not observe R1's name listed. LPA and LPM reviewed staff roster and did not observe any employee with a name
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 11-AS-20230906083302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING
FACILITY NUMBER: 198205024
VISIT DATE: 09/07/2023
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
similar to "Manny." LPA and LPM conducted a tour of the facility and did not observe any bedroom listed with the number indicated in complaint details.

LPA and LPM could not clarify details of the complaint allegation with the reporting party (RP) as no contact information is listed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation us unsubstantiated.

Exit interview conducted with Administrator Lorenzona Medina, and a copy of this report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2