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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 08:41:59 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:
12:30 PM
MET WITH:Administrator Shalani RamosTIME COMPLETED:
02:15 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 citations observed during complaint investigation 11-AS-20230811161937, LPA met with Administrator Shalani Ramos as the purpose of todays visit was explained.

During the complaint investigation, LPA observed resident #1 (R1) had a change in condition and facility staff did not document such changes in residents record. Also, during complaint investigation during interviews conducted facility staff communicated with R1's physician when R1 refused medication but there was no documentation of the communication and the physicians directives.

Deficiencies cited under California code regulations, title 22, division 6, chapter 8 are being cited on the attached 809D.
exit interview conducted, appeal rights explained, and a copy of this report was provided
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)
Page: 1 of 2


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
05/13/2024
Section Cited
CCR
87566

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Observation of the Resident
...When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physicians and the
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Licensee shall develope a plan outlining the steps the facility will take when residents have change in conditions and how such changes shall be documented in residents file. Licensee shall submit plan to licensing by POC due date.
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resident's responsible person, if any. Based on interviews conductedand reocrds reviewed, R1 had a change in condition in physical and mental functioning, and R1 was refusing meds and the licensee failed to document shuch changes. This poses a health and safety risk to residents in care.
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Type B
05/13/2024
Section Cited
CCR87465(d)(2)

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Incidental Medical and Dental Care
If the resident is unable to determine his/her own need for a prescription...The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.
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Licensee shall develope a plan outlining the steps the facility will take to ensure documented contact with physician and physicans directions is maintained in rseidents records. Licensee shall submit plan to licensing by POC due date.
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This requirement is not met as evident by based on interviews conducted and records review, the licensee failed to document contact with R1's physician when R1 refused medication(s). This poses a 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