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 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 speech. Based on interviews, records, and observations, there was insufficient evidence to support the allegation, resulting in an unsubstantiated finding.

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. Staff and residents denied witnessing any inappropriate sexual behavior. One resident (R1) was noted to have paranoid delusions and agitated behavior. Records reviewed did not support the allegation. The complaint was unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as a review of relevant records, did not support the claim that staff failed to prevent inappropriate interactions. 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 alleged that a resident exposed themselves to another resident. Staff and residents denied witnessing such behavior. The resident involved has a history of schizoaffective behavior and psychosis, which may cause delusions. The allegation was unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as review of medical and facility records, indicated no witnessed inappropriate interactions. The allegation was determined to be unsubstantiated and 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 involved allegations of staff neglect causing hospitalization and medication mishandling. The investigation included interviews with staff and residents, review of medical and incident reports, and medication logs. The allegations were found unsubstantiated due to lack of preponderance of evidence.

The investigation found that although there were allegations that a resident missed medication leading to hospitalization, the evidence was insufficient to substantiate the claims. The resident was admitted with pre-existing kidney failure, and medication noncompliance was noted but not proven to have caused the hospitalization. The allegation was 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 investigation was triggered by allegations that facility staff opened residents' mail without consent and asked residents for money outside of monthly rent fees. The allegations were unsubstantiated after interviews and document reviews.

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 requests. The allegations were determined to be unsubstantiated.

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

The investigation found that the details of the complaint allegation did not match information obtained during the investigation. The resident named in the complaint was not found on the resident roster, and no evidence supported the allegation. Therefore, the complaint was unsubstantiated.

The complaint involved three allegations: staff not ensuring resident took prescribed medications, failure to notify responsible party of medical condition changes, and failure to properly address resident's change in condition. All allegations were found unsubstantiated based on interviews and documentation review.

The investigation found all allegations unsubstantiated after interviews with staff, residents, and review of records. There was 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 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 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 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 facility was found to be clean, in good repair, and compliant with all applicable regulations. No deficiencies or citations were issued during the 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.

No deficiencies were observed during the inspection. The facility was found to be clean, well-maintained, and in compliance with regulations, including proper medication administration and safety measures.

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. The complaint was determined to be unsubstantiated with no citations 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.

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 lack of supervision leading to repeated assaults of Resident #1 by Resident #2. The investigation included interviews with staff and residents, review of incident and medical reports, and law enforcement documentation. The allegation was found unsubstantiated.

The investigation found that an incident occurred on 01/14/20 where Resident #1 was assaulted by Resident #2, resulting in injury requiring medical treatment and law enforcement involvement. However, interviews and record reviews did not reveal staff failed to provide adequate care or supervision, and there was no prior history of altercations between the residents. Therefore, the allegation was 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 alleged that Resident #1 was physically assaulted multiple times by Resident #2 due to lack of staff supervision. The investigation included interviews with staff, residents, and administrators, review of incident reports, medical records, and law enforcement reports. The allegation was found unsubstantiated due to insufficient evidence.

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

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 investigation was unsubstantiated. Allegations included inappropriate speech to a resident and failure to provide eating assistance. Interviews and record reviews did not confirm these allegations.

The investigation included interviews with staff and residents, record review, and a physical tour. Both allegations were found unsubstantiated due to lack of preponderance of evidence proving 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 complaint was unsubstantiated. Allegations included a resident found unclothed without body covering and staff failing to seek medical attention. Investigations included interviews with staff and the resident, file reviews, and observation. Despite the allegations possibly being valid, there was no preponderance of evidence to prove violations occurred.

The investigation found insufficient evidence to substantiate the allegations. Staff and the resident reported no knowledge of why the resident was unclothed, and medical attention was appropriately sought for the resident's severe rash and other conditions. 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 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 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.

The complaint alleged a resident found a cockroach in her bed. After a 10-day investigation including interviews and facility tour, the allegation was 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 determined 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.

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 disrespectful staff behavior. Interviews and observations did not support these claims.

The investigation included interviews with residents, staff, and the administrator, as well as inspection of shower drains and review of documents. The allegations were found to be 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 was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.

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 based on interviews with residents and staff, and observations made during the visit.

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 reasons related to Covid-19.

The complaint was unsubstantiated after investigation. Allegations included residents not having access to water and being isolated in their rooms, but evidence did not prove violations occurred.

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

The complaint alleged that a resident had multiple unwitnessed falls resulting in hospitalization. Interviews and record reviews indicated 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, and no citations were issued.

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 was unsubstantiated after interviews with staff and residents, review of incident and medical reports, and a telephonic investigation due to COVID-19 mitigation measures.

The investigation found inconsistent statements regarding the allegation and insufficient evidence to substantiate that the resident was assaulted 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 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 investigation was conducted telephonically due to COVID-19 mitigation measures. Interviews with residents and the administrator indicated no forced medication administration. The allegation was unsubstantiated.

The investigation found no preponderance of evidence to prove the allegation that residents were forced to take medications. Residents stated they take medications voluntarily and are aware of their rights to refuse medication. 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.