198205024-5-24-2021-11-AS-MCAA-C4YSSF-20210716140749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 05/21/2021
Date Signed: 05/24/2021 09:50:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/23/2020 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20200923153630

FACILITY NAME:	HACIENDA GRANDE SENIOR ASSISTED LIVING		FACILITY NUMBER:	198205024
ADMINISTRATOR:	MARIANNE A HODEL		FACILITY TYPE:	740
ADDRESS:	1740 GRAND AVENUE		TELEPHONE:	(562) 597-7753
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY:	120	CENSUS: 44	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Elvie Medina		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Call light are in disrepair.
Resident left unattended for an extended period of time after a fall.

INVESTIGATION FINDINGS:

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05/21/21 Licensing Program , Analyst Jade Jordan conducted a subsequent complaint visit, regarding the allegations listed above. Today’s complaint investigation was conducted with Lorenzona "Elvie" Medina, the facility Administrator.

Investigation consisted of the following: Sampled 5 bedrooms; toured receptionist desk, obtained facility staff roster, resident roster, attempted interviews conducted with (11) residents, and administrator.

Evaluation Report Continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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-20200923153630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING	FACILITY NUMBER: 198205024
	VISIT DATE: 05/21/2021

NARRATIVE

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Allegation: The call light is in disrepair.

The investigation reveals that room # 127’s intercom only works intermittently, LPA tested the intercom twice in the same day, hours apart, and found that the call system is not working consistently.
It was also found that room # 116 is missing a pull chord, and call button next to residents’ bed.

The Department has investigated the above allegation, based on information gathered, and LPA’s observation there is sufficient evidence to support the above allegation. Therefore: the preponderance of evidence standard has been met, and the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

Allegation: Resident left unattended for an extended period of time after a fall.

The investigation revealed according to LPA interviews that some resident indicated it took some time for staff to get to them after a fall. it was generally stated it did not take longer than 15 mins, according to resident interviews. None of the falls by residents resulted in hospitalization, and staff came to assist either from their rounds or by indication of call light. Therefore; the preponderance of evidence standard has been met, and the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200923153630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HACIENDA GRANDE SENIOR ASSISTED LIVING	FACILITY NUMBER: 198205024
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited CCR 87303(i)(1)(A)	1 2 3 4 5 6 7	Maintenance and Operation (i)(1)(A) (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A)Operate from each resident's living unit. Based On LPA Observation the standard of evidence was not met. Call light was not consistency working. These poses a potential health, safety, personal rights in care.	1 2 3 4 5 6 7	Admin will give a form of communication such a bell for resident room whos calllight boxes dont work. Admin will do mothly rounds to ensure call system is working, and keep log of rooms that need attention. Submit plan to LPA by 06/11/21
Type B 06/11/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (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. Based On LPA interviews the standard of evidence was not met. Residents were left on floor for unspecified amount of time. These poses a potential health, safety, personal rights in care.	1 2 3 4 5 6 7	Admin will provide in service training about checking on residents timely. Will submit proof of staff attendance to LPA by 06/11/21
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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