198205024-1-9-2025-11-AS-JHAD-DD95Z5-20250124192323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:37:50 PM

Unsubstantiated

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
02/05/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240205224822

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: 50	DATE:	01/09/2025
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Administrator Lorenzona Medina		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff neglect resulted in a resident being hospitalized .
Client did not receive medication as prescribed.

INVESTIGATION FINDINGS:

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On 01/09/25 Licensing Program Analysts (LPAs) Villegas and Day conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator (A1) Lorenzona Medina as the purpose of today’s visit was explained.

The investigation consisted of the following: On 02/07/24 LPA obtained a copy of the staff and residents rosters, conducted a tour, there were no immediate health and safety concerns, conducted a medication review, conducted interview with staff 1 (S1), and obtained copies of the following: Resident #1 (R1) complete file, incident report dated 01/29/24, order summary report dated 01/04/24, communication log for 01/04/24 and 01/28/24, and medication technician communication log dated 01/25/24 and 01/29/24.On 01/09/25 LPAs obtained a copy of the resident and staff rosters, on 01/09/25 between 10am- 10:45 am LPAs conducted interviews with residents #2-6 (R2-R6), and between 11am- 11:15am LPAs conducted interview with Administrator (A1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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 3

Control Number 11-AS-20240205224822

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: 01/09/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff neglect resulted in a resident being hospitalized.

It is being alleged that resident did not receive high blood pressure medication which resulted resident being hospitalized with kidney failure. On 02/07/24 LPA Villegas interviewed staff 1 (S1) regarding the allegation above, S1 denied the allegation above and reported that on 01/24/24 the VA sent residents cycle meds to the SNF where resident was previously receiving treatment. Per S1, VA Dr. and Dr. reported medications would be re-sent to Hacienda Grande Senior Living. On 07/30/24 LPA Villegas conducted a review of R1’s medical records from St. Mary medical center in Long Beach from dates 1/29/2024 through 2/08/2024, per medical records resident was admitted on 01/29/24 diagnosis of visit being shortness of breath, acute renal injury, and hyperkalemia. On 02/07/24 LPA Villegas conducted a review of R1’s physicians report dated 12/18/23 and preplacement appraisal dated 12/18/23 which revealed R1 was diagnosed with acute kidney failure upon admission to the Hacienda Grande Senior Living. On 11/24/24 the department conducted a review of R1’s medical records from St. Mary medical center in Long Beach from dates 1/29/2024 through 2/08/2024 which upon review it was determined it would be difficult to prove that missing any medications for a few days would have contributed to kidney failure since R1 already was at CKD stage 5, which is kidney failure (or close to failing) requiring dialysis or kidney transplant for survival. On 01/09/25 between 10am- 10:45 am LPAs conducted interviews with R2-R6, 5 of 5 residents interviewed denied the allegation above. On 01/09/25 between 11am- 11:15am LPAs conducted interview A1 regarding the allegation above, A1 denied the allegation above and reported R1 was admitted to Hacienda Grande Senior Assisted Living with diagnosis of Kidney failure.

Allegation: Staff mishandled a resident's medication while in care.

It is being alleged that R1 was without medication for just a few days.

On 02/07/24 LPA Villegas interviewed S1 regarding the allegation above, S1 confirmed the allegation above and reported that 3 days’ worth of medication were found in residents’ bedroom on 01/25/24. Per S1 R1 was reminded of the importance of medication compliance, per S1 moving forward staff will watch R1 take medications. On 02/07/24 LPA Villegas conducted a review and confirmed that the facility sent CCLD an incident report dated 01/25/24 reporting that R1 did not take AM nor PM medications on 01/22/24, 01/23/24, and on 01/24/24.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240205224822

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: 01/09/2025

NARRATIVE

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On 12/30/24 LPA Villegas conducted a review of R1’s Physicians report dated 12/18/23 which indicates R1 can administer own prescribed meds, able to administer own PRN’s and R1 is able to store own meds. On 12/30/24 LPA Villegas conducted a review of PM shift med-tech communication log dated 01/24/24, per S1 01/25/24 3 days’ worth of bedtime medications found, when questions R1 reported R1 forgot to take the medication. On 02/07/24 LPA Villegas conducted a conducted a medication review and did not observe any discrepancies. On 01/09/25 between 10am- 10:45 am LPAs conducted interviews with R2-R6, 3 of 5 residents interviewed denied the allegation above. 2 of 5 residents interviewed reported going without medications for 3 days, 2 of 5 residents reported obtaining medications after making appointment and having prescription sent to the pharmacy. On 01/09/25 between 11am- 11:15am LPAs conducted interview with A1 regarding the allegation above, A1 denied the allegation and reported staff administered R1 medications as prescribed, however staff did not watch R1 take medications as it is documented on R1’s Physicians report dated 12/18/23 that R1 can take own meds. A1 continued to report that on 01/25/24 (3) days’ worth of medication were found in residents’ bedroom by staff, which was reported to CCLD.

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 Lorenzona Medina, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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