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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:08:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241014150005
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: 49DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rodrigo RamosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Unlawful eviction.
Facility staff open resident's mail without permission.
INVESTIGATION FINDINGS:
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On 10/23/24, at 9:35am, Licensing Program Analysts (LPAs) Perry Scott and Wendy Gibbs conducted an initial complaint visit to the facility and was greeted by Lorenzona Medina (S2), Administrator, and Rodrigo Ramos (S1), Licensee. LPAs explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint.

The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S3) and residents (R1-R6). Additionally, LPA obtained the following facility documents: Resident Roster (Dated: 1/04/2024), Staff Roster (Dated: 1/10/2024), Admission Agreement (Dated: 07/25/2024), Eviction Notice (Dated: 9/11/2024) Copy of Check (Dated: 08/26/2024 & 08/30/2024) Physicians Report (Dated: 07/20/2024), ID/Emergency Information (Dated: 07/25/2024), Flex Notes (Dated: 08/14/24, 09/20/24, and10/09/24), Medication Administration Record Receipt of Meds (Dated:10/08/24), Rent Invoice (Dated: 08/01/24, 09/01/24, 10/01/24) and Email Notice (Dated: 10/09/24) from the facility.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 11-AS-20241014150005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/23/2024
NARRATIVE
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The investigation revealed the following: Allegation #1- Unlawful eviction.

The details of the complaint alleged that the licensee issued the resident (R1) an eviction notice on 9/11/2024 due to possible non-payment. On 10/23/24, from 09:35am-12:30pm, LPAs interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 2 of 3 staff (S1- S3) denied the allegation that the facility issued an Unlawful eviction. Staff (S1-S2) stated that they did not issue a 30-day eviction notice to R1 but rather a notice that the rent was past due and that R1 had not paid any rent since R1 was admitted on 07/25/24, and if not received, then the facility would issue an eviction letter. One staff had no knowledge of an eviction notice. LPA reviewed the notice and observed that in the heading of the letter it says, “This letter shall serve as a 30 day notice to vacate room 229A because of failure to pay the services rendered by Hacienda Grande”. LPA also reviewed the rent invoices (Dated: 08/01/24, 09/01/24, 10/01/24) that shows a past due balance of rent unpaid.

LPA interviewed residents R1-R6 about the allegation and 1 of 6 residents that were interviewed corroborated the allegation that the facility issued an Unlawful eviction. Resident (R1) stated that they issued an eviction letter to them on 9/11/24. 5 of 6 residents stated that they have not been issued an eviction notice.

Based on interviews and records reviewed the Licensee, (S1) failed to serve R1 with an eviction notice in accordance with tittle 22 regulations. A review of the eviction notice dated 09/11/24, revealed the following items were not included in the eviction notice: The eviction notice was missing resources and referrals for R1, a statement regarding if R1 stays at the facility an unlawful detainer shall be filed. Also, a written copy of the eviction notice was not issued to Community Care Licensing (CCLD) within 5-days. The facility stated that they mailed a copy to the Monterey Park office on 09/11/24. CCLD received the eviction notice on 10/09/24. Moreover, a statement indicating the residents right to file a complaint with CCLD and the contact information for the Long-Term Care Ombudsman was missing from the eviction letter. Therefore, the above allegation Unlawful eviction, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) deficiencies are being cited on the attached LIC 9099D.

Allegation #2- Facility staff open resident's mail without permission.

The details of the complaint alleged that the facility opened the residents’ (R1) mail without consent, including the residents’ social security checks. On 10/23/24, from 09:35am-12:30pm, LPAs interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 2 of 3 staff (S1-S3) denied the allegation that the Facility staff open resident's mail without permission. S1 stated that all mail that are checks with their name on it (Hacienda Grande) are opened and processed. And any other mail that is not addressed to Hacienda Grande and are addressed to the residents are not opened. LPA reviewed the copy of two checks and observed that R1s name was on the check above the facilities name. The name and address of the facility below R1s name is the facility that R1 is residing at, and therefore should not have been opened.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20241014150005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/23/2024
NARRATIVE
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LPA interviewed residents (R1-R6) about the allegation and 1 of 6 residents that were interviewed corroborated the allegation that the Facility staff open resident's mail without permission. R1 stated that the facility had no right to open R1s mail because it was not addressed to the facility but to R1 only. 5 of 6 residents stated that they have not had an issue with the facility opening their mail.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Facility staff open resident's mail without permission, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) Deficiencies are being cited on the attached LIC 9099D.

Citations were issued, and plans of corrections were discussed.

Note: *Citations not cleared by the due date will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

An exit interview was conducted with Rodrigo Ramos, Licensee, and a copy of this Complaint Investigation Report and appeal rights were provided.


SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20241014150005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87224(d)(1)(B)(C)(D)
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87224(d)(1)(B)(C)(D) Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction... (1) The notice to quit shall include the following information: (B) Resources available to assist ...Referral services...(C) A statement informing residents of their right to file a complaint with the licensing agency…(D)…the residential care facility for the elderly must file an unlawful detainer action. This requirement is not met as evidenced by:
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R1 no longer resides in the facility. In the future, Administrator will submit an eviction notice that is in compliance with Title 22 regulations, 87224(d)(1)(B)(C)(D) Eviction Procedures. Administrator will submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.
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Based on interviews and records reviewed, the licensee failed to serve resident (R1) with an eviction notice in accordance with tittle 22 regulations. This poses a potential personal rights risk to residents in care.
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Type B
10/30/2024
Section Cited
CCR
87468.1(a)(1)(3)
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87468.1(a)(1)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
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Licensee to review Personal Rights of Residents 87468.1(a)(1)(3) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.
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Based on a record review of the eviction notice dated 9/11/24. The licensee failed to ensure the residents’ personal rights due to the nature of and items in the eviction notice to the resident by making inappropriate statements. The licensee stated in the eviction notice that the resident knows how to ride the system, is a manipulator, and threatened to have R1 removed from a state funded program, which poses a potential personal rights 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: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20241014150005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87468.1(a)(15)
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87468.1(a)(15) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement is not as evidenced by:
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Licensee/Administrator shall read Title 22, Section 87468.1(a)(15) Personal Rights of Residents... and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.
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Based on interviews, the licensee failed to ensure resident's personal rights due to staff opening their personal mail without prior consent.
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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: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241014150005

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: 49DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rodrigo RamosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not provide a safe environment for the residents.
INVESTIGATION FINDINGS:
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Allegation- Facility staff did not provide a safe environment for the residents.

The details of the complaint alleged that the facility did not provide a safe environment for the resident (R1) because R1s former resident threw a chair at R1. On 10/23/24, from 09:35am-12:30pm, LPAs interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 4 of 4 staff (S1-S4) denied the allegation that the Facility staff did not provide a safe environment for the residents. All staff (S1-S3) stated that the facility does provide a safe environment for the residents. They state that R1 was in an altercation with R1s roommate and that they abruptly took steps to separate the two and changed rooms to separate them before it became physical. They state that they took the appropriate actions to prevent any further altercations.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20241014150005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/23/2024
NARRATIVE
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LPA interviewed residents (R1-R6) about the allegation and 1 of 6 residents that were interviewed corroborated the allegation that the Facility staff did not provide a safe environment for the residents. The majority of residents (5 of 6) interviewed stated that the facility does provide a safe environment and that they are happy with the care and supervision provided by the staff.

Based on interviews, there is insufficient evidence to support the allegation that the Facility staff did not provide a safe environment for the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Rodrigo Ramos, Licensee, and a copy of this Complaint Investigation Report and appeal rights were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7