198205024-7-28-2023-11-AS-JCAN-CU5UFS-20230727153314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205024
Report Date: 07/27/2023
Date Signed: 07/28/2023 11:20:04 AM

Document Has Been Signed on 07/28/2023 11:20 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HACIENDA GRANDE SENIOR ASSISTED LIVING		FACILITY NUMBER:	198205024
ADMINISTRATOR:	LORENZONA ELVIE MEDINA		FACILITY TYPE:	740
ADDRESS:	1740 GRAND AVENUE		TELEPHONE:	(562) 597-7753
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY:	120	CENSUS: 46	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	OWNER RODRIGO RAMOS		TIME COMPLETED:	03:30 PM

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	On 07/27/2023 at 12:00 noon, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Hacienda Grande Senior Assisted Living Facility. LPA Calderon was allowed entry into the facility by Owner Rodrigo Ramos. The facility is licensed for 120 residents age 60 and over. Currently, there are forty-six (46) residents residing in the facility 60 years or older. LPA Calderon explained to Owner Rodrigo Ramos, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) resident service records, six (6) resident medication records, and LPA Calderon interviewed six (6) residents and six (6) staff members for visit. LPA Calderon inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 04/20/2022. The two-story commercial building consists of sixty (60) resident bedrooms, sixty (60) resident bathrooms, six (6) common bathrooms, dining room, commercial kitchen, staff room, office area, library, washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons are stored in the premises. Commercial Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage is in the basement of the facility.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms #100, #103, #106, #200, #206, #210: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 115 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 112 degrees Fahrenheit, and Bathroom #3 hot water temperature properly measured at 111 degrees Fahrenheit. Commercial kitchen hot water temperature properly measured at 112 degrees Fahrenheit. Facility sixty (60) Carbon Monoxide and sixty (60) Smoke Detectors hard wired and connected were tested and are working properly. The facility twenty (20) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked medication room. Facility first aid six (6) kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Six (6) staff files were checked and have the required documents. The facility does not handle resident's money/cash resources. All the required documents are posted in the facility in a clearly visible area. LPA Calderon noted the Administrator Elvie Medina Certification # 6053801740 expiration date of 10/02/2023 was valid at time of visit. Commercial General Liability Policy #NAL-CA-2021-12161-23 policy period from 04/09/2023 to 04/09/2024 and a Commercial Professional Liability Insurance Policy #NAL-CA-2021-12161-23 policy period from 04/09/2023 to 04/09/2024 underwritten by National Assisted Living Risk Retention Group Inc coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Owner Rodrigo Ramos who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 08/06/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023

NARRATIVE

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LPA advised the Owner Rodrigo Ramos to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Owner Rodrigo Ramos.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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