198205024-6-3-2021-11-AS-MCAA-C5DW5H-20210729165907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:03:58 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
05/25/2021 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210525100850

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: 43	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Lorenzona Medina, Administrator		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident found a cockroach in her bed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jennifer Jones initiated a 10 day complaint investigation and delivered findings for the allegation listed above. During today’s visit, LPA Jones met with administrator, Lorenzona Medina and explained the reason for the visit.

During today's visit on 06/03/21, LPA Jones discussed the allegation with the administrator, Lorenzona Medina, and requested the following documents: Staff and resident rosters and resident 6's identification sheet, admission agreement, physician report, 30 day notice and pest control invoices for the past 90 days. LPA Jones and the administrator toured the facility inside and outside. LPA observed the following rooms: Rm 112, rm 116, rm 123, rm 127, rm 203, rm 211, rm 214, rm 217, rm 219, rm 220 and rm 223. LPA Jones observed the sheets and bathrooms in each resident room. LPA checked the kitchen and observed perishible and non perishible food items, facility common areas, dining toom and library. During the visit, LPA Jones interviewed 6 staff and 5 residents.
The allegation revealed the following: For allegation (resident found a cockroach in her bed). It is being

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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 2

Control Number 11-AS-20210525100850

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: 06/03/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

that a resident found a cockroach in their bed. During the tour, LPA Jones observed the rooms to be in title 22 regulation. LPA Jones did not observe bugs(cockroach) in the resident bedrooms. LPA Jones did not observe and bugs in the kitchen or common areas. Residents 1-5 revealed during their interviews that they like living in the facility, they have not observed any bugs (cockroaches) in their rooms or any other areas in the facility. Residents 1-5 stated that housekeeping come in to clean their rooms once a week. The residents stated that housekeeping change their sheets when they come to clean their rooms and housekeeping also cleans their bathrooms.
The administrator stated during her interview that she has not observed any cockroaches or bugs in the facility. The administrator stated that she has not received any complaints from the residents or staff about cockroaches. The administrator stated that housekeeping cleans the facility several times throughout the day. The administrator stated that pest control sprays the facility once a month and provided LPA Jones with invoices. LPA Jones did not observe any evidence of cockroaches on the invoices the administrator provided. Staff 2-6 revealed during their interviews that they have not observed cockroaches or other bugs in the resident rooms, kitchen or others areas in the facility. Staff 2-6 stated that if pest are observed during their shift then they will report it to management right away. Staff 2-6 stated that they observe housekeeping cleaning the facility daily. Staff 2-6 stated that they have not received any complaints from the residents regarding cockroaches. Staff 4 revealed during her interview that deep cleaning is done once a week in 4-5 resident bedrooms. Staff 4 stated that during that time, in addition to the standard cleaning (changing the bedding and surfaces) housekeeping moves the furniture around cleans behind those areas too.

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.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2