HACIENDA GRANDE SENIOR ASSISTED LIVING

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction 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.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: A health screening as specified in Section 87411, Personnel Requirements - General. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff #2-4 do not have a completed and physician signed health screening which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/11/2025 Plan of Correction Licensee and Administrator to obtained a complete and physician signed health screening for staff #2-4, and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Deficient Practice Statement Based on [(observation) and (interview)the licensee did not comply with the section cited above as during facility tour LPA gibbs observed bedroom #206 to be without a smoke detector which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/11/2025 Plan of Correction Licensee to ensure all bedrooms whether occupied or vacant have a working smoke detector in place.

Official classification

Type B

Official code

87224(d)(1)(B)(C)(D)

Regulation authority

CCR

What the official deficiency says

87224(d)(1)(B)(C)(D) Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction... (1) The notice to quit shall include the following information: (B) Resources available to assist ...Referral services...(C) A statement informing residents of their right to file a complaint with the licensing agency…(D)…the residential care facility for the elderly must file an unlawful detainer action. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to serve resident (R1) with an eviction notice in accordance with tittle 22 regulations. This poses a potential personal rights risk to residents in care.

Official plan of correction

R1 no longer resides in the facility. In the future, Administrator will submit an eviction notice that is in compliance with Title 22 regulations, 87224(d)(1)(B)(C)(D) Eviction Procedures. Administrator will submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (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. This requirement is not met as evidenced by: Based on a record review of the eviction notice dated 9/11/24. The licensee failed to ensure the residents’ personal rights due to the nature of and items in the eviction notice to the resident by making inappropriate statements. The licensee stated in the eviction notice that the resident knows how to ride the system, is a manipulator, and threatened to have R1 removed from a state funded program, which poses a potential personal rights risk to residents in care.

Official plan of correction

Licensee to review Personal Rights of Residents 87468.1(a)(1)(3) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(15)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(15) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement is not as evidenced by: Based on interviews, the licensee failed to ensure resident's personal rights due to staff opening their personal mail without prior consent.

Official plan of correction

Licensee/Administrator shall read Title 22, Section 87468.1(a)(15) Personal Rights of Residents... and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 10/30/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the downstairs library has a wall in disrepair and is dirty which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Licensee shall make repairs to the downstairs library wall and submit proof to LPA Villegas by POC due date.

Official classification

Type B

Official code

87412(e)

Regulation authority

CCR

What the official deficiency says

Personnel Records In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above as there was no LIC 500 nor a document detailing facility staff titles nor listed work days and hours made available during LPAs visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Licensee to complete an LIC 500 and submit it to LPA Villegas by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

Personnel requirements- General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. Deficient Practice Statement Based on [(observation), (interview), and (record review)], the licensee did not comply with the section cited above as LIC 503 was observe without physicians signature which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2024 Plan of Correction Licensee to have staff complete a health screening and obtain a signed LIC 503 form by the physician conducting the health screening. Licensee to provide proof to LPA Villegas by POC due date.

Official classification

Type B

Official code

87566

Regulation authority

CCR

What the official deficiency says

Observation of the Resident ...When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physicians and the resident's responsible person, if any. Based on interviews conductedand reocrds reviewed, R1 had a change in condition in physical and mental functioning, and R1 was refusing meds and the licensee failed to document shuch changes. This poses a health and safety risk to residents in care.

Official plan of correction

Licensee shall develope a plan outlining the steps the facility will take when residents have change in conditions and how such changes shall be documented in residents file. Licensee shall submit plan to licensing by POC due date.

Deadline recorded: May 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care If the resident is unable to determine his/her own need for a prescription...The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evident by based on interviews conducted and records review, the licensee failed to document contact with R1's physician when R1 refused medication(s). This poses a health and safety risk to residents in care.

Official plan of correction

Licensee shall develope a plan outlining the steps the facility will take to ensure documented contact with physician and physicans directions is maintained in rseidents records. Licensee shall submit plan to licensing by POC due date.

Deadline recorded: May 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidet by, based on records review the licensee did not submit incident reports dated 4/17/24, and 4/19/24 to licensing within 7 days of the occurence. This poses potential health and safety risk to residents in care.

Official plan of correction

Administrator to review title 22 reporting requirementsand self certify acknowledgement of the review. Administrator shall submit self certification by POC due date.

Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions: Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers). The standard of evidence was not met: based on the evidence provided, R1 was diagnosed with unstageable and Stage 4 dermal ulcers on 02/22/21 and 02/24/21 and referred to a higher level of care due to requiring total care. This poses an immediate health, safety and personal rights risk to residents in care

Official plan of correction

The administrator shall read Title 22, Section " Prohibited Health Conditions " , send a written statement to CCL by the POC date that she will ensure to stay in constant communication with the medical professional and if the resident's medical condition elevate; meaning they require a higher level of care, they will ensure the resident is relocated to a SNF or hospital, the relocation will take place immediately. Because the administrator retained R1 as a resident at the facility for several months after the Home Health Agency skilled nurse stated a higher level of care due to total care, civil penalties are assessed in the amount of: $000.00 for retaining Resident #1 for several months with a prohibited health condition. The plan is due to the CCLD/El Segundo ASC Office by POC due date.

Deadline recorded: Apr 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. Licensee failed to observe or conduct an assessment of Resident #1’s level of care during which time the resident was receiving home health care services while at the facility from 01/26/21 thru 02/25/21. On 02/22/21, Resident #1 was diagnosed with a “right hip pressure ulcer – Stage 4” – measured: 5x5.5 x 0.8 cm. On 02/24/21, HHA Registered Nurse recommended R1 be referred to a higher level of care; as the resident required total care. On 02/25/21, R1 was transferred to Long Beach Memorial Medical Center for wound debridement. This poses an immediate health, safety, personal rights risk to residents in care

Official plan of correction

Administrator will review Title 22 Regulations, Section 87466 and submit a detailed written plan on how the facility will document and address changes in resident conditions. The plan is due to the CCLD/El Segundo ASC Office by POC date of 04/11/22.

Deadline recorded: Apr 11, 2022. A deadline is not proof that correction was completed.