Inspection Reports for
Hacienda Grande Assisted Living

The allegation was that staff spoke to residents inappropriately. Interviews with 6 residents and 6 staff members revealed denials of the allegation. An Unusual Incident Report showed no documented evidence of inappropriate staff communication. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation included interviews with residents and staff, review of relevant documents, and facility observation. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The complaint involved neglect and lack of care and supervision, specifically retaining a resident with a prohibited health condition needing a higher level of care due to pressure injuries. The Department substantiated the allegation on April 8, 2022, and is pursuing an enhanced civil penalty for serious bodily injury.

The Department substantiated the allegation of neglect and lack of care and supervision on April 8, 2022, and is reviewing the complaint for an enhanced civil penalty related to serious bodily injury. A civil penalty totaling $10,000 is pending.

The complaint was substantiated on April 8, 2022, for neglect and lack of care and supervision involving a resident with pressure injuries. The Department is reviewing for an enhanced civil penalty pursuant to Health and Safety Code Section 1569.49(e) for serious bodily injury.

The Department substantiated neglect and lack of care and supervision on April 8, 2022, and is reviewing the complaint for an enhanced civil penalty related to serious bodily injury. A civil penalty totaling $10,000 was noted for serious bodily injury.

The complaint alleged that a resident exposed themselves to another resident. Interviews with staff and residents, as well as review of medical and appraisal records, found no evidence to support the allegation. The resident involved was noted to have a mental condition causing paranoid delusions. The allegation was unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation. Staff and most residents denied witnessing inappropriate interactions, and records reviewed did not support the complaint. The allegation was determined to be unsubstantiated and no citations were issued.

The complaint alleged that a resident exposed themselves to another resident. Interviews with staff and residents, and review of medical and appraisal records for the resident who made the allegation, indicated the resident has schizoaffective behavior and psychosis. The allegation was determined to be unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to substantiate the allegation. Staff and most residents denied witnessing inappropriate sexual interactions, and the resident who made the allegation has a documented history of mental health issues including paranoid delusions. No citations were issued.

The complaint involved allegations that staff neglect resulted in a resident being hospitalized due to missed high blood pressure medication, and that the resident was without medication for a few days. The investigation included interviews with staff, residents, and review of medical records and incident reports. The allegations were found unsubstantiated due to lack of preponderance of evidence.

The investigation found that although there were allegations of medication mishandling and staff neglect leading to hospitalization, the evidence was insufficient to substantiate the claims. Resident medical records and interviews indicated the resident was admitted with kidney failure and that medication noncompliance was partly due to the resident's own actions. The allegations were ultimately unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included facility staff opening residents' mail without consent and asking residents for money outside of monthly rent fees. Interviews and document reviews did not support these claims.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with the administrator, licensee, staff, and residents denied the allegations, and residents reported no issues with mail or financial handling. The allegations were determined to be unsubstantiated.

The complaint alleged that staff did not ensure a resident was taking prescribed medications, failed to notify the resident's responsible party of a change in medical condition, and failed to properly address the resident's change in condition. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found the allegations unsubstantiated after interviews with staff, residents, and review of records showed no evidence that staff failed to ensure medication intake, notify responsible parties of medical condition changes, or properly address resident condition changes.

The facility was found to be clean, in good repair, and compliant with all applicable regulations. No deficiencies or citations were issued during this inspection.

The Licensing Program Analyst found the facility to be clean, in good repair, and compliant with all applicable regulations. No deficiencies or citations were observed during the inspection.

The complaint alleged that a resident was being threatened by another resident. After interviews with 5 staff members and 6 residents, and review of relevant documents, the Licensing Program Analyst found no reports or evidence supporting the allegation. The complaint was unsubstantiated.

The investigation, including interviews with staff and residents and review of facility documents, found no evidence to support the allegation that a resident was being threatened by another resident. The allegation was determined to be unsubstantiated and no citations were issued.

The complaint alleged lack of supervision resulting in Resident 1 being assaulted multiple times by Resident 2. The investigation included interviews with staff and residents, review of incident and medical reports, and law enforcement documentation. Resident 1 was treated for fractured fingers after being hit with a cane by Resident 2. Staff were not aware of the assaults prior to the incident. The allegation was unsubstantiated.

The investigation found that an incident occurred on 01/14/20 where Resident 1 was assaulted by Resident 2 and sustained injuries requiring medical treatment. Staff responded by obtaining medical care and separating the residents. Interviews and record reviews did not reveal evidence of inadequate supervision or prior altercations. The allegation was determined to be unsubstantiated due to insufficient evidence.

The complaint alleged that lack of supervision resulted in a resident being assaulted multiple times by another resident. The investigation included interviews with staff and residents, review of incident and medical reports, and law enforcement documentation. The allegation was found unsubstantiated due to insufficient evidence.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff, residents, and review of medical and incident reports showed that staff provided timely medical care and supervision, and there was no prior history of altercations between the residents involved. The allegation was determined to be unsubstantiated.

The complaint involved allegations that a resident was spoken to inappropriately and was not provided assistance with eating. The investigation found no evidence to substantiate these allegations.

The investigation included interviews with staff and residents, record review, and a physical tour. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations did or did not occur.

The complaint was unsubstantiated. Allegations included a resident found naked without body covering and staff failing to seek medical attention. Investigation included interviews with staff and the resident, review of medical records, and observation. The resident was diagnosed with shingles and cellulitis and had been sent to the hospital as advised. The resident voluntarily discharged against medical advice but returned with medical diagnoses and advice. No preponderance of evidence was found to prove violations.

The investigation found insufficient evidence to substantiate the allegations. Interviews and file reviews indicated uncertainty about how the resident became unclothed and confirmed that medical attention was sought appropriately. No citations were issued.

The facility was found to be generally compliant with no citations issued. Minor technical advisories were given for cosmetic scuffs in the first-floor hallway and normal wear and tear on the second-floor carpet. Safety features, food supply, medication storage, and COVID-19 protocols were observed to be in proper order.

The complaint alleged a resident found a cockroach in her bed. The allegation was investigated and found unsubstantiated.

The investigation found no evidence of cockroaches in resident rooms, kitchen, or common areas. Interviews with residents, staff, and the administrator confirmed no observations or complaints of cockroaches. Pest control invoices showed regular monthly treatments. The allegation was unsubstantiated due to lack of preponderance of evidence.

Complaint allegations included residents not having access to water and residents being isolated in their rooms. The complaint was unsubstantiated based on interviews and observations.

The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews indicated residents had access to water and were not isolated except for protective measures against COVID-19. The complaint was determined to be unsubstantiated.

The complaint alleged that a resident sustained multiple unwitnessed falls resulting in hospitalization. Interviews revealed the resident had issues with methamphetamine use contributing to falls. Other residents reported no issues with falls. The allegation was unsubstantiated.

The investigation included resident and staff interviews and record reviews related to falls. The allegation was found to be unsubstantiated due to lack of preponderance of evidence to prove the violation occurred.

The complaint alleged lack of supervision resulting in a resident being assaulted on several occasions by another resident. The investigation found inconsistent statements and insufficient evidence to support the allegation. The complaint was unsubstantiated.

The investigation included interviews with staff, residents, and review of records. The statements were inconsistent and there was insufficient evidence to substantiate the allegation of assault due to lack of supervision. The allegation was determined to be unsubstantiated.

The complaint alleged that a resident was forced to take unknown medications. The allegation was investigated through resident interviews and discussion with the administrator. The complaint was found to be unsubstantiated.

The investigation found that residents generally stated they take their medications voluntarily and are not forced. The administrator confirmed that only trained staff pass out medications and residents have the right to refuse medications, which is documented. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was initiated based on allegations of inadequate care and missing personal items. After interviews and document review, the allegations were determined to be unsubstantiated.

The investigation included interviews with residents and the administrator conducted via virtual video call due to COVID-19. Residents generally reported satisfaction with care and supervision and denied missing personal items. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.