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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205024
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:41:49 PM


Document Has Been Signed on 06/20/2024 02:41 PM - 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: 42DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Licensee Rodrigo RamosTIME COMPLETED:
02:45 PM
NARRATIVE
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On 06/20/24 Licensing Program Analyst’s (LPA’s) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Licensee Rodrigo Ramos as the purpose of the visit was explained. LPA’s were later joined by acting Administrator Shalani Ramos. The facility is licensed to serve 60 ambulatory and 60 non-ambulatory residents ages 60 and above. The facility has an approved hospice waiver for 10 residents. The current facility census is 46 residents in care. An active liability insurance was observed to have an expiration date of 04/09/25. Licensee was provided with information regarding the annual fee of $1,982 due by 06/26/24.

The facility is two-story commercial building consists of sixty (60) resident bedrooms, sixty (60) resident bathrooms, six (6) common bathrooms, dining room, commercial kitchen, med room, library, washer and dryer/ storage area, backyard with umbrella with table and chairs, and administrative offices. 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. Toxins and knifes were stored and inaccessible to residents. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. Exits and walkways are free of debris/hazards, there are no weapons nor bodies of water on the premises.

LPA’s conducted a records review of 5 staff records, 4 resident records, and 4 medication reviews. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 01/22/24, fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational. LBFD conducted a fire inspection on 04/16/24, facility is in compliance.

Deficiencies are cited on 809D page.

Exit interview conducted, appeal rights explained to licensee, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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 3


Document Has Been Signed on 06/20/2024 02:41 PM - 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the downstairs library has a wall in disrepair and is dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee shall make repairs to the downstairs library wall and submit proof to LPA Villegas by POC due date.
Type B
Section Cited
CCR
87412(e)
Personnel Records

In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as there was no LIC 500 nor a document detailing facility staff titles nor listed work days and hours made available during LPAs visit
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee to complete an LIC 500 and submit it to LPA Villegas by POC due date.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/20/2024 02:41 PM - 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel requirements- General
All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
Deficient Practice Statement
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Based on [(observation), (interview), and (record review)], the licensee did not comply with the section cited above as LIC 503 was observe without physicians signature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee to have staff complete a health screening and obtain a signed LIC 503 form by the physician conducting the health screening. Licensee to provide proof to LPA Villegas by POC due date.

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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3