Inspection Reports for Hacienda Grande Assisted Living

An unannounced complaint investigation visit was conducted to investigate the allegation that staff spoke to residents inappropriately.

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 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.

An office meeting was held to discuss Complaint 11-AS-20210226154939 regarding an allegation of neglect and lack of care and supervision involving a resident with a prohibited health condition requiring a higher level of care due to pressure injuries.

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 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 visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-06-24 alleging that staff did not prevent a resident from engaging in inappropriate interactions with another resident.

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, 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 inspection was an unannounced complaint investigation visit conducted to investigate an allegation that staff did not prevent a resident from engaging in inappropriate interactions with another resident in care.

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 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.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for Hacienda Grande Senior Assisted Living Facility.

The facility was found generally compliant with licensing requirements, including clean and operational kitchen, proper medication storage, and functional safety equipment. However, two Type B deficiencies were cited: incomplete health screenings for staff #2-4 and a missing smoke detector in bedroom #206.

The visit was an unannounced complaint investigation regarding allegations of staff neglect resulting in a resident being hospitalized and a resident not receiving medication as prescribed.

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 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 inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-10-14 regarding unlawful eviction, facility staff opening resident's mail without permission, and failure to provide a safe environment for residents.

The investigation substantiated two allegations: unlawful eviction due to improper eviction notice procedures and facility staff opening a resident's mail without permission. The allegation that the facility did not provide a safe environment was unsubstantiated based on interviews and evidence.

The complaint included allegations of unlawful eviction, facility staff opening resident's mail without permission, and failure to provide a safe environment. The first two allegations were substantiated, citing violations of Title 22 regulations and personal rights. The third allegation was unsubstantiated due to insufficient evidence.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.

The facility was generally clean, safe, and operational with proper maintenance of kitchen, resident rooms, and safety equipment. However, deficiencies were cited related to maintenance of the downstairs library wall, incomplete personnel records, and missing physician's signature on health screening forms.

The visit was a case management inspection conducted to issue a deficiency related to reporting requirements after the facility failed to submit unusual incident reports within the required 7-day timeframe.

The facility did not submit two unusual incident reports dated 04/17/24 and 04/19/24 to the licensing agency within 7 days as required by California code regulations, posing a potential health and safety risk to residents.

The visit was a case management inspection conducted to issue deficiencies observed during a complaint investigation (11-AS-20230811161937). The Licensing Program Analyst met with the Administrator to explain the purpose of the visit.

The investigation found that resident #1 had a change in condition that was not documented in the resident's record. Additionally, communication with the resident's physician regarding medication refusal was not documented, posing a health and safety risk.

The visit was triggered by complaint investigation 11-AS-20230811161937. Deficiencies were substantiated related to failure to document changes in resident condition and failure to document communication with the physician regarding medication refusal.

The visit was an unannounced complaint investigation conducted in response to allegations that facility staff were opening residents' mail without consent and asking residents for money outside of monthly rent fees.

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 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.

An unannounced complaint investigation was conducted due to an allegation that a resident developed a pressure injury due to staff neglect.

The investigation found no evidence to substantiate the allegation. Interviews and record reviews did not confirm the presence of the named resident or staff involved, and no supporting evidence was found during the facility tour and document review.

The complaint alleged that due to staff neglect, a resident developed a pressure injury while in care. The allegation was unsubstantiated due to lack of evidence and inability to verify the resident or staff involved.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-08-11 regarding medication administration, notification of medical condition changes, and proper addressing of resident condition changes.

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 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 inspection was an unannounced annual inspection visit conducted to evaluate compliance with regulatory requirements at Hacienda Grande Senior Assisted Living Facility.

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 inspection was an unannounced 1-year annual inspection visit conducted to evaluate compliance with licensing regulations at Hacienda Grande Senior Assisted Living Facility.

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.

An unannounced complaint investigation visit was conducted due to an allegation that a resident was being threatened by another resident in care.

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 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.

Unannounced complaint investigation visit conducted due to allegations that a resident sustained multiple pressure injuries while in care and that the facility retained a resident with a prohibited health condition.

The investigation substantiated that Resident #1 sustained multiple pressure injuries while in care and that the facility retained the resident despite a prohibited health condition requiring a higher level of care. The facility failed to transfer the resident promptly, resulting in civil penalties.

The complaint investigation was substantiated. Resident #1 sustained multiple pressure injuries and was retained by the facility despite requiring a higher level of care. The allegations of neglect/lack of supervision and level of care were substantiated.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 01/21/2020 alleging lack of supervision resulting in a resident being assaulted by another resident.

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 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 inspection was an unannounced complaint investigation visit triggered by an allegation that lack of supervision resulted in a resident being assaulted on several occasions by another resident.

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 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.

An unannounced complaint investigation was conducted following allegations that a resident was spoken to inappropriately and was not provided assistance with eating while in care.

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 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.

An unannounced complaint investigation visit was conducted in response to allegations that a resident was found naked with no body covering with the air conditioning on, and that staff did not seek medical attention for the resident.

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 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.

An unannounced annual inspection control visit was conducted to evaluate the facility's compliance with safety, privacy, comfort, and regulatory requirements.

The facility was found to be in compliance 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 such as smoke detectors, fire extinguishers, and medication storage were functioning properly.

The visit was an unannounced complaint investigation triggered by a complaint received on 2021-05-25 regarding a resident finding a cockroach in her bed.

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.

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

An unannounced complaint investigation was conducted due to allegations that facility showers were unsanitary and staff were not treating residents with dignity and respect.

After interviews with residents, staff, and the administrator, and inspection of shower drains and cleanliness, the allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included unsanitary showers and staff disrespect towards residents, but evidence did not support these claims.

The inspection was an unannounced complaint investigation triggered by an allegation received on 08/27/2020 regarding the front door being padlocked at the facility.

The investigation found sufficient evidence to substantiate the allegation that the front door was padlocked by a night staff member, which violated residents' personal rights. The staff was spoken to and the issue did not recur. The deficiency was cited under CCR 87468.1(a)(6).

The complaint was substantiated based on interviews with residents, staff, and the administrator, and review of documents. The allegation was that the front door was padlocked, which was confirmed by the investigation.

The inspection was an unannounced complaint investigation visit triggered by allegations including call lights being in disrepair and residents being left unattended for an extended period after a fall.

The investigation substantiated that call lights were not consistently working, including specific issues in rooms #127 and #116, and that some residents were left on the floor for up to 15 minutes after a fall, though no hospitalizations occurred. Both allegations were supported by evidence and interviews.

The complaint investigation was substantiated. Allegations included call lights in disrepair and residents left unattended after falls. Interviews and observations confirmed these issues, with no hospitalizations resulting from falls.

The inspection was an unannounced complaint investigation triggered by allegations received on 09/23/2020 regarding call light disrepair and residents being left unattended after a fall.

The investigation substantiated both allegations: the call light system was found to be inconsistently working with missing components in some rooms, and residents were left unattended for periods generally not exceeding 15 minutes after falls, with no hospitalizations reported.

The complaint investigation was substantiated based on evidence gathered and interviews. Allegations included call light disrepair and residents left unattended after falls. The preponderance of evidence standard was met for both allegations.

The visit was an unannounced complaint investigation triggered by allegations received on 12/15/2020 regarding residents not having access to water and being isolated in their rooms.

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.

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 visit was an unannounced complaint investigation triggered by allegations that residents did not have access to water and were isolated in their rooms.

Based on interviews with residents and staff, and observations during the visit, there was no evidence to substantiate the allegations. Residents had access to water and were not isolated except for protective reasons related to COVID-19.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained multiple unwitnessed falls at the facility resulting in hospitalization.

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 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 inspection was conducted as an unannounced complaint investigation following a complaint received on 2020-01-21 alleging lack of supervision resulting in a resident being assaulted by another resident.

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 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 inspection was conducted as an unannounced complaint investigation following a complaint received on 07/09/2020 alleging that a resident was forced to take unknown medications.

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 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 inspection was an unannounced complaint investigation triggered by allegations that staff were not providing appropriate care and supervision to residents and that residents' personal items had gone missing.

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.

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.