198205024-7-23-2026-11-AS-MLEN-DW9PMH-20260723112621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205024
Report Date: 07/23/2026
Date Signed: 07/23/2026 11:26:48 AM

Document Has Been Signed on 07/23/2026 11:26 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	HACIENDA GRANDE SENIOR ASSISTED LIVING		FACILITY NUMBER:	198205024
ADMINISTRATOR/ DIRECTOR:	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: 45	DATE:	07/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:07 AM
MET WITH:	Lorenzona Medina - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:08 PM

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On 07/23/26 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. California Department of Social Services (CDSS) met with Lorenzona Medina - Administrator as the purpose of the visit was explained.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. Annual fees are current and liability insurance is valid through 04/09/27.

The facility is two-story commercial building consists of (60) resident bedrooms, (60) resident bathrooms, (6) common bathrooms, dining room, commercial kitchen, med-room, library, washer and dryer/storage area, a shaded sitting area, 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. Four (4) 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 was measured between 133.3 - 139.6°F (degrees Fahrenheit) which is outside of title 22 regulation. Please see LIC809-D. 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 4 staff records, 4 resident records, and 4 medication reviews. Medications were centrally stored and properly locked, first aid kit was checked, fully stocked, and located in the medication room.

Report continues, please see LIC809-C.

Ulysses Coronel
Mario Leon
	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING	FACILITY NUMBER: 198205024
	VISIT DATE: 07/23/2026

NARRATIVE

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The last disaster drill was conducted on 05/05/26, fire extinguishers fully charged, carbon monoxide and smoke detectors are operational. LBFD conducted a yearly fire inspection, last conducted on 01/27/26, facility is in compliance.

There has been one deficiency cited during today's visit. Please see LIC809-D.

An exit interview was held with Lorenzona Medina - Administrator, and a copy of facilities' appeal rights, one deficiency and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/23/2026 11:26 AM - It Cannot Be Edited

Created By: Mario Leon On 07/23/2026 at 10:23 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation)], the licensee did not comply with the section cited above in four [4] out of [4] [RM103: 139.6°F, RM 121: 136.8°F, RM 202: 133.3°F, RM 221: 136.7°F] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2026
	Plan of Correction
1 2 3 4	LPA and Administrator Lorenzona have agreed that the facility will maintain pictures of rooms 103, 121, 202, 221 water temperature for seven (7) days within title 22 regulation, from 105-120°F. Administrator will forward imagery to LPA via email at MARIO.LEON@DSS.CA.GOV.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Mario Leon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC809 (FAS) - (06/04)

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