198205024-5-6-2024-11-AS-JHAD-D54VJN-20240509162901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 09/07/2023
Date Signed: 05/06/2024 02:20:54 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
08/11/2023 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230811161937

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: 47	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Lorenzona Medina		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not ensure resident was taking prescribed medications.
Facility did not notify resident's responsible party of a change in resident's medical condition.
Facility staff failed to properly address residents change in condition.

INVESTIGATION FINDINGS:

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On 05/06/243 at 1:00pm m, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Administrator Shalani Ramos and the purpose of today’s visit was explained.

The investigation consisted of the following: On 08/17/23 LPA interviewed Administrator, staff #1-3 (S1-S3), interviewed residents # 2-6 (R2-R6) and Witness #1 on 08/22/23. LPA is unable to interview resident #1 during the investigation. LPA obtained copies of the following for R1's; Emergency Identification form, Pre placement appraisal, physician’s report, med lists, Conservatorship paperwork, email interactions between facility and responsible party, physician orders, staff and resident rosters. On 08/17/23 LPA conducted a medication review of 8 resident medications.

The investigation revealed the following:
Allegation- Staff did not ensure resident was taking prescribed medications.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (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)

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Control Number 11-AS-20230811161937

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

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It is alleged the staff was seen leaving medications in R1’s room without confirmation of their intake, and the Administration could not provide an explanation or policy regarding this. On 08/17/23 LPA interviewed Administrator regarding the above allegation, AD denied the allegation above. Per AD’s, all three med techs are ensuring residents especially dementia residents are taking their meds before walking away. AD’s continued to state that the facility does not use a medication administration record (MAR), however med refusals are documented and PCP is informed. When asked if R1 refused meds, AD stated that when R1 wasn't in a good mood R1 would refuse psych meds. Higher level of care was suggested by AD to family as staff had a hard time administering meds due to refusals. Per AD, normally telephone calls to sister or conservator were made to report med refusals. On 08/17/23, LPA interviewed S1—S3, 3 out of 3 staff interviewed denied the above allegation. S1 reported that staff only documents med refusals in the Mar and Doctor is notified if med refusals continue. On 08/17/23 LPA interviewed residents # 2-6 about the above allegations, 5 out of 5 residents denied the allegation above. On 08/17/23 LPA conducted file review of R1 file and did not observe any documented medication refusals

Allegation: Facility did not notify resident's responsible party of a change in resident's medical condition.
It is alleged the Facility did not notify resident's responsible party of a change in resident's weight gain and leg edema. On 08/17/23 LPA interviewed Administrator regarding the above allegation, AD denied the allegation above. Per AD, there was communication via telephone and email with responsible party and Doctor. On 08/17/23 LPA interviewed S1—S3, 3 out of 3 staff interviewed denied the above allegation. Per S1-S3 if any change in condition is observed Administrator is informed and Administrator notifies responsible party. LPA conducted review of emails dated 9/12/2022 and 09/18/2022 and observed that there was communication between R1’s responsible party and facility about R1’s change in condition. On 08/22/23 LPA and LPM interviewed witness #1 (W1) regarding the allegation above, W1 indicated being made aware by facility staff of R1's change of medical condition. On 08/17/23 LPA interviewed residents # 2-6 about the above allegations, 5 out of 5 residents denied the allegation above.

Allegation: Facility staff failed to properly address residents change in condition.
It is alleged the facility staff failed to properly address resident # 1’s leg edema. On 08/17/23 LPA interviewed Administrator regarding the above allegation, AD denied the allegation above. Per AD, there was communication via telephone and email with responsible party and Doctor. LPA and LPM interviewed Witness #1 regarding the allegation, witness #1 confirmed that when there are any changes in condition the facility staff would notify primary care physician. Witness # 1 stated that if there were any changes in condition, witness #1 would come out to the facility. LPA interviewed S1—S3, 3 out of 3 staff interviewed denied the above allegation. 1 of 3 staff interviewed stated that staff reports to med techs and administration. 2 out the 3 staff interviewed denied the allegation and confirmed that Doctor is aware of change in condition. LPA interviewed residents #2-6, 5 out of 5 residents did not have any knowledge of allegation but did confirm facility Doctor visits facility monthly. On 08/17/23 LPA conducted a review of R1's file and did not observe any documentation regarding leg edema

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 is Unsubstantiated.
Exit interview conducted with Administrator Shalani Ramos and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (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)

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