198205024-5-21-2021-11-AS-MVAO-C68NCY-20210825102131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205024
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:29:31 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
08/27/2020 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20200827144843

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:	01:29 PM
MET WITH:	Elvie Medina		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Front Door Is being Padlocked

INVESTIGATION FINDINGS:

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05/21/21 Licensing Program Analyst LPA/Jade Jordan initiated a subsequent complaint investigation from 08/31/21 for the allegation listed above. Today’s subsequent complaint investigation was conducted with Lorenzona Medina, the facility Administrator.

The Investigation consisted of the following: Toured Entry ways, and exits, obtained facility staff roster, Resident roster, interviews conducted with (3) staff and (5) clients.

Continued On 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-20200827144843

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 front door is padlocked.

The investigation reveals that the front door of the facility had been “locked” by a caregiver, at night, for unspecified amount of time. LPA interviewed Residents 1-5, Administrator, and 3 staff.

Administrator stated that a night staff had locked the front facility door. The shift was a 10pm- 7am shift. Administrator stated that the staff was spoken to about this, and that it did not happen again. The time and date could not be recalled.

The Department has investigated the above allegation, based on information gathered, LPA did find sufficient evidence to support allegation “Front Door is being Padlocked”

Based on LPA’s interviews which were conducted, and review of other documents received, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (LIST NUMBER) and Chapter (LIST NUMBER) are being cited on the attached LIC 9099D.

An exit interview was conducted with Lorenzona Medina, and a hard copy, all with appeal rights were provided.

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-20200827144843

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 05/21/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468(a)(6) Personal RIghts.Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department	1 2 3 4 5 6 7	Administrator provided in service training once made aware of the situation. POC cleared same day.
	8 9 10 11 12 13 14	Based On LPAS interviews this standard was not met and poses a potential health and safety and personal rights violations to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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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