198205024-7-15-2021-11-AS-MCAA-C5AVBC-20210726161718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 07/15/2021
Date Signed: 07/15/2021 03:34:31 PM

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
07/08/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210708145101

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:	07/15/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elvie Medina		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Authorized representative found resident naked with no body covering with the air conditioning on.
The staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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On 07/15/21 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent visit in regardsTo the allegations above. LPA was met by Administrator Elvie Medina, and the Purpose of the visit was explained.

The Investigation Revealed:

In regard to: Authorized representative found resident naked with no body covering with the air conditioning on.

On 06/24/21 The Reporting Party (RP) found Resident 1 (R1) in her room with no clothes. R1 was not alert when she was found. Interviews were conducted with staff (S1-4) who worked from 6am-2pm. (S1-2) Am staff stated, including Administrator that they observed R1 to be clothed prior to shift changed on 06/24/21. The next change of shift started at 2pm. During this shift R1’s Authorized Representative/RP found R1 in her room without clothes in just a sheet. LPA interviewed a total of 5 Caregivers from Morning shift (6am-2pm) and Afternoon shift (2pm-10pm), and three Med Tech’s who work Am, and Pm on that day.

Unsubstantiated

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: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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-20210708145101

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: 07/15/2021

NARRATIVE

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All staff interviewed stated that R1 did not request for assistance, to be dressed or undressed. LPA interviewed R1 and R1 stated she had no idea why she was undressed on 06/24/21 and that she really doesn’t know. She answered LPA that she can dress and undress herself. R1 doesn’t not have a diagnosis of Dementia, but Physician Report indicates some forgetfulness. On 06/24/21 R1 was still recovering from a body rash known as shingles.

Based On Lpa interviews conducted with staff and R1, it is unclear how the resident became unclothed. Therefore; although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

In Regard to: The staff did not seek medical attention for resident.

On 06/06/21 R1 was observed by Med Tech 1 to have multiple severe rashes on body. Med Tech 1 contacted the Dr. Reid and provided pictures of the rash to the Doctor. The Doctor advised R1 needs to be sent to the hospital ASAP. RP was contacted by Med Tech 1 via text on 06/06/21. Med Tech informed in text that R1 has “Severe Rash” and was being sent to Long Beach Memorial. RP was contacted again via text 06/07/21 by Med Tech 1, that R1 had returned to the facility. According to Discharge Paperwork. R1 was diagnosed with Cellulitis (skin Infection) Fungal Skin Rash, and Shingles.

On 06/24/21 the paramedics were called by the facility when R1’s vitals were low. According to interviews with RP, R1 was having a hard time being woken up. R1 was sent to the hospital. During file Review it was observed by LPA that R1 opted to voluntarily discharge herself against Medical advice on 06/25/21. R1 returned to the Assisted Living Facility with Shingles Diagnosis along with another diagnosis, and medical advice.

Based on Lpa interviews, file review, and observation the department finds that although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview conducted and copy this report given administrator. No citations were issued during this visit.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC9099 (FAS) - (06/04)

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