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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205024
Report Date: 05/06/2024
Date Signed: 05/07/2024 08:41:11 AM


Document Has Been Signed on 05/07/2024 08:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 44DATE:
05/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Shalani RamosTIME COMPLETED:
02:00 PM
NARRATIVE
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On 05/06/24 at 1pm Licensing program analyst (LPA) Villegas conducted a case management visit to issue deficiency for reporting requirements, LPA Met with Administrator Shalani Ramos as the purpose of todays visit was explained.

On 04/30/24 LPA received two unusual incident reports, the first incident report was dated 04/17/24 but was not received by the department until 04/30/24 (13 days). The second unusual incident report was dated 04/19/24 but was not received by the department until 04/30/24 (11 days). Based of review of the incident reports the facility staff did not submit the unusual incident reports within 7 days of the occurrence as required by title 22.

Deficiency cited under California code regulations, title 22, division 6, Chapter 8 are being cited on the attached LIC 809D.

Exit interview conducted, appeal rights provided, and a copy of this report was provided to
Administrator Shalani Ramos.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 08:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING
FACILITY NUMBER: 198205024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87211(a)(1)

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Each licensee shall furnish to the licensing agency...
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
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Administrator to review title 22 reporting requirementsand self certify acknowledgement of the review. Administrator shall submit self certification by POC due date.
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This requirement is not met as evidet by, based on records review the licensee did not submit incident reports dated 4/17/24, and 4/19/24 to licensing within 7 days of the occurence. This poses potential health and safety 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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2