Atria Hacienda

On 09/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced 1 year required visit. LPA met with Nathan Boese, Assistant Executive Director and informed of the purpose of the visit. The facility is licensed to serve. The facility has an approved hospice waiver for (16) residents with (9) currently receiving services. There are (61) residents receiving home health services and (3) residents that are self administering oxygen. A file review was conducted prior to making today's visit. The facility annual fees have been paid, and the governing body was observed to be in good standing. Below are the observations made during today's visit. The facility was observed to be clean and the passageways being free of any obstructions. The facility was observed to have the required postings. The fire extinguishers were fully charged and last serviced on 03/12/25. The emergency disaster drills are being conducted on a monthly basis, with the last drill being conducted on 09/19/25. The smoke and carbon monoxide detectors were observed to be operable and were being serviced during LPAs visit. The pull cords were randomly tested and found to be operable. The pool was observed to be secured. There are no known guns or ammunition on the premises. The hot water tested and found to be within regulatory limits. The medications and medication carts were locked inside the medication room. The facility is using and electronic MAR system. The sharps and chemicals were observed to be locked and inaccessible to residents in care. A file review of both staff and resident files were conducted. All staff interviewed and files reviewed were observed to have obtained criminal record clearance and to be associated to the facility. The Resident Medical Assistant staff were observed to possess valid CPR certification. The administrator Monique Moreira was observed to have valid certification that expires on 02/19/26. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The resident files reviewed and are indicated on the LIC-811, confidential names list revealed that one (1) of the residents residing in memory care had not received an annual medical assessment. However the request was submitted on more than one occasion with the last time being on 07/19/25. All other documentation such as admissions agreements and appraisals were present. Additionally LPA verified contact information on file, and will update accordingly. A copy of the facility's liability insurance was obtained for the facility file at the regional office. Based on today's inspection the facility was inspected in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). No citations were issued An exit interview was conducted where a copy of this report, 809C, appeal rights were reviewed and provided to Nathan Boese, Assistant Executive Director.

Investigation Revealed the Following: Allegation: Resident was sexually assaulted while in care. The details of the complaint alleged that (R#1) was sexually assaulted by (R#2) while living at the facility. On August 3, 2025, at approximately 8:30 am, during the records review, the department observed the Riverside County Sheriff’s Department Report # T232650034 dated:9/22/23. The department noticed that the deputy assigned to investigate (R#1)’s alleged sexual assault by (R#2). After interviewing (R#1), the deputy stated that there were no signs of forceful interaction and that it was more likely consensual between (R#1) and (R#2). In addition, the department reviewed the copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:12/14/22, the department observed that it was written on (R#1)’s assessment that they have a mild cognitive impairment, they are not confused or disoriented, are able to follow instructions, and able to communicate their needs. Moreover, the department reviewed the copy of (R#1)’s Preplacement Appraisal Information or LIC 603 dated:2/23/23, and the department observed that it was written that (R#1) ’s mental condition was alert, oriented, and did not need special supervision due to confusion or forgetfulness. Additionally, the department reviewed the copy of Staff Roster or LIC 500 dated: September 2023, the department observed that the day of (R#1)’s incident 9/22/23 at approximately 9:00 am, there were (5) caregivers in the memory care unit, the department noticed there were enough facility staff to provided care and supervision to (R#1 and R#2) and the rest of the residents. On October 6, 2023, the department interviewed the Assistant Executive Director (A#1). She stated that the incident between (R#1) and (R#2) was reported to her by (S#1). Additionally, (A#1) stated that she was told by (S#1) that (R#1) was not in distress after the incident happened. The day before the incident, (S#1) observed (R#1) and (R#2) “happy” and holding hands. Moreover, (A#1) stated that it was observed through the facility’s video surveillance cameras in the hallway (R#1) and (R#2) showing signs of affection to each other. In addition, (A#1) mentioned that the police department was called, but they found no issues after their investigation. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On October 6, 2023, the department interviewed facility staff 1 (S#1); they stated that the day of the incident between (R#1) and (R#2), increased supervision was in place for (R#1) and (R#2). Also, (S#1) stated that when the police came to investigate the incident, they determined that the incident between (R#1) and (R#2) was consensual. On October 6, 2023, the department interviewed facility staff member 2 (S#2). They reported that they consistently observed residents 1 (R#1) and 2 (R#2) sitting together at mealtimes and holding hands. (S#2) also stated that they have never witnessed (R#2) forcibly grab (R#1) to kiss them. Additionally, (S#2) mentioned that when (R#2) approaches (R#1) to kiss their cheek, (R#1) leans forward, and there is no indication of any force involved. On October 6, 2023, the department interviewed Witness 1 (W#1), who stated that they were present on the day of the incident involving (R#1) and (R#2). Additionally, (W#1) also mentioned that the day before the incident, they observed (R#1) and (R#2) sitting on a couch having a conversation. On October 6, 2023, the department interviewed resident 1 (R#1); they stated that they don’t know who R#2 is, nor can they remember their name. Also, (R#1) stated that they have not been out with any male, and they don’t have any male friends. On October 6, 2023, the department interviewed resident 2 (R#2); they stated that when they see R#1, they always greet them. (R#2) said that they don’t know (R#1)’s name or room number. Additionally, (R#2) stated that both themselves and (R#1) were only kissing and hugging, and no intimate interaction happened. Moreover, (R#2) indicated that they did not force anyone to be intimate with them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Teresa Ramirez/Community Business Director.

Investigation Revealed the Following: Allegation: Staff are financially abusing resident. The details of the complaint alleged that facility staff is taking (R#1)’s money. On August 2, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated: 9/1/24, it is mark that (R#1) has a cognitive impairment that may affect their decision making and judgment. In addition, LPA Iniguez reviewed (R#1)’s Durable Power of Attorney for Management of Property and Personal Affairs dated: 11/5/21. LPA Iniguez observed that (W#1) is the appointed agent for all (R#1)’s personal properties and financial decisions. Moreover, LPA Iniguez reviewed (R#1)’s (R#1)’s Residency Agreement dated: 9/1/2024, LPA Iniguez observed that the agreement has a Theft and Loss policy in place that follows the Health and Safety Code sec. 1569.13, this clause was reviewed and signed by (W#1) decision agent for (R#1). On August 2, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that the facility has a Theft and Loss policy in place and is also found on the residents’ agreements. In addition, (A#1) stated that she does not think the facility staff was financially abusing (R#1) or any other resident in care. On August 2, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked them if they have ever witnessed or known that facility staff are financially abusing (R#1) or taking their personal belongings, (W#1) responded, "No, I have never observed any staff doing that to (R#1). I visit them every other day unannounced, so I would notice right away if something like that was happening." Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On August 2, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked them if they have ever witnessed or known that facility staff are financially abusing (R#1) or taking their personal belongings, (W#1) responded, "No, I have never observed any staff doing that to (R#1). I visit them every other day unannounced, so I would notice right away if something like that was happening." On 8/2/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On August 2, 2025, at approximately 11:00 AM, during interviews with residents (R#2-R#9), (9) out of (10) stated that the facility staff had never taken any of their personal belongings. On August 2, 2025, at approximately 1:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they had never taken (R#1) 's or any other resident in care's personal belongings. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Claudia Herrera/ Administrative Assistant. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 8/2/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On August 2, 2025, at approximately 11:00 AM, during interviews with residents (R#2-R#9), (6) out of (10) stated that their family manages their finances, and (2) out of (10) stated that they manage their finances. Additionally, (9) out of (10) stated that the facility staff have never financially abused them. On August 2, 2025, at approximately 1:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they treat all the residents with dignity and respect. Also, (5) out of (5) facility staff stated that they have not financially abused (R#1) or any other resident in care. Allegation: Staff do not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is taking (R#1)’s personal property. On August 2, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated: 9/1/24, it is mark that (R#1) has a cognitive impairment that may affect their decision making and judgment. In addition, LPA Iniguez reviewed (R#1)’s Durable Power of Attorney for Management of Property and Personal Affairs dated: 11/5/21. LPA Iniguez observed that (W#1) is the appointed agent for all (R#1)’s personal properties and financial decisions. Moreover, LPA Iniguez reviewed (R#1)’s (R#1)’s Residency Agreement dated: 9/1/2024, LPA Iniguez observed that the agreement has a Theft and Loss policy in place that follows the Health and Safety Code sec. 1569.13, this clause was reviewed and signed by (W#1) decision agent for (R#1). On August 2, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that the facility has a Theft and Loss policy in place and is also found on the residents' agreements. In addition, (A#1) stated that she does not think the facility staff was taking (R#1) or any other resident's personal belongings. Evaluation Report continues LIC 9099-C

The department conducted interviews with staff #1-#5 (S1-S5) and residents #3-#10 (R3-R10) and was unable to interview R1-R2. Furthermore, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and common areas. The investigations revealed the following: Allegation: Staff are charging resident for services not rendered. It is being alleged that a resident is paying an additional $700.00 a month to include additional housekeeping but the service is not being provided. On 06/17/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff stated that residents are receiving the services they are paying for based on their care plan. S1 stated that all residents receive housekeeping once a week, and if additional housekeeping is needed then the residents will then pay an additional fee. S1 stated that this facility has care levels 1-6 with different rates, and staff will then follow the residents’ care plan to meet the residents needs. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 8 out of 8 residents stated they are not being charged for services not rendered to them. 8 out of 8 residents said they are satisfied with the services provided to them. The department conducted a review of records on 07/13/25. A Resident Functional Needs Care Profile for R1 dated: 06/21/24 revealed that R1 was receiving additional housekeeping needs. R1 was receiving assistance with making bed daily and taking trash out once per day at 10:00 AM. A Resident Functional Needs Care Profile for R2 dated: 06/21/24 revealed that R2 was receiving additional housekeeping needs. R2 was receiving assistance with making bed daily and taking trash out once per day at 08:30 AM. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff are not providing residents with privacy. It is being alleged that staff were asked to stay in the resident’s apartment to watch over a resident. On 07/12/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff said they did not know anything about the allegation. 5 out of 5 staff stated that they have not been asked to stay in a resident’s apartment to watch over a resident. S1 stated that they are not aware of staff in a resident’s apartment watching over them, but if that was to happen, it’ll only be in accordance with that resident’s care plan and the residents’ needs. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 8 out of 8 residents stated that they are not aware if a staff member was in a resident’s apartment to watch over them. 8 out of 8 residents stated that a staff member has not been asked to stay in their apartment to watch over them. 8 out of 8 residents said they are satisfied with the services provided to them at this facility. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Office Director, Teresa Ramirez, and a copy of this report is provided.

Investigation Revealed the Following: Allegation: Resident sustained unexplained bruises while in care. The details of the complaint alleged that (PR#1) sustained unexplained bruises. On 7/13/25, at approximately 8:00 AM, during the records review, the department observed a copy of the Riverside County Sheriff's Department Incident Report dated:12/23/2023. In the report, it is written that a deputy was dispatched to an elder abuse call at the facility. The deputy spoke with (PR#1), who stated that they did not recall how they sustained their injury. Additionally, (PR#1) immediately stated that nobody did that to them, "it could have done it to myself while I was asleep, I do not recall how the injury occurred". On 1/19/24, during an interview with resident 1 (PR#1), they stated that they did not know how the injury might have happened; they assumed that while they were asleep, one of their hand rings might have been the cause. Additionally, (PR#1) stated that neither the facility staff nor the agency caregivers had assaulted them, (PR#1) said "I would have known if those things had happened to me". On 2/9/24, during an interview with witness 1 (PW#1), they stated that (PR#1) never called them to inform them that someone at the facility had assaulted them. Additionally, the department asked (PW#1) if they believed (PR#1) was in any danger residing at the facility, (PW#1) stated “no”. Also, the department asked (PW#1) if they felt anyone at the facility physically assaulted (PR#1), causing their injury; (PW#1) stated they did not. On 2/14/24, during an interview with witness 2 (PW#2), they stated that they saw (PR#1)’s injury and asked them what happened. (PR#1) stated that they did not know what happened. Also, (PR#1) stated that they did not fall, nor did anyone assault them. Additionally, (PW#2) stated that they believe (PR#1) was “very smart”; they feel that (PR#1) would remember if something happened to them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 3/6/24, during an interview with witness 3 (PW#3), they stated that (PR#1) explained to them that they just woke up that morning, and they had a mark under their eye. (PW#3) stated that they asked (PR#1) if anyone had struck them; they said no one had struck them. Also, (PW#3) asked (PR#1) if they felt, and they said no. Additionally, (PW#3) stated that they suspected (PR#1) quite possibly rolled over onto something in their sleep, or invertedly hit their face on something in the middle of the night. On 1/19/24, during an interview with Assistant Executive Director (PA#1), they stated that the facility staff informed them about (PR#1)’s injury, and they had observed their injury. Additionally, (PA#1) stated that they asked (PR#1) what happened, and they just replied that they had a little injury and did not know how they sustained it. On 1/19/24 and 3/13/24, during interviews with staff members 1 and 2 (PS#1 and PS#2), they reported noticing (PR#1)’s injury and inquired about the incident. (PR#1) stated that they could not recall what had happened. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Theresa Ramirez/Business Office Director.

The department conducted interviews with staff #1-#5 (S1-S5) and residents #3-#10 (R3-R10) and was unable to interview R1-R2. Furthermore, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and common areas. The investigations revealed the following: Allegation: Staff are charging resident for services not rendered. It is being alleged that a resident is paying an additional $700.00 a month to include additional housekeeping but the service is not being provided. On 06/17/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff stated that residents are receiving the services they are paying for based on their care plan. S1 stated that all residents receive housekeeping once a week, and if additional housekeeping is needed then the residents will then pay an additional fee. S1 stated that this facility has care levels 1-6 with different rates, and staff will then follow the residents’ care plan to meet the residents needs. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 8 out of 8 residents stated they are not being charged for services not rendered to them. 8 out of 8 residents said they are satisfied with the services provided to them. The department conducted a review of records on 07/13/25. A Resident Functional Needs Care Profile for R1 dated: 06/21/24 revealed that R1 was receiving additional housekeeping needs. R1 was receiving assistance with making bed daily and taking trash out once per day at 10:00 AM. A Resident Functional Needs Care Profile for R2 dated: 06/21/24 revealed that R2 was receiving additional housekeeping needs. R2 was receiving assistance with making bed daily and taking trash out once per day at 08:30 AM. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff are not providing residents with privacy. It is being alleged that staff were asked to stay in the resident’s apartment to watch over a resident. On 07/12/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff said they did not know anything about the allegation. 5 out of 5 staff stated that they have not been asked to stay in a resident’s apartment to watch over a resident. S1 stated that they are not aware of staff in a resident’s apartment watching over them, but if that was to happen, it’ll only be in accordance with that resident’s care plan and the residents’ needs. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 8 out of 8 residents stated that they are not aware if a staff member was in a resident’s apartment to watch over them. 8 out of 8 residents stated that a staff member has not been asked to stay in their apartment to watch over them. 8 out of 8 residents said they are satisfied with the services provided to them at this facility. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Office Director, Teresa Ramirez, and a copy of this report is provided.

Investigation Revealed the Following: Allegation: Staff do not provide resident with housekeeping services. The details of the complaint alleged that facility staff is not cleaning (R#1)’s room. On July 12, 2025, at approximately 2:00 PM, during a Health and Safety check of the facility, LPA Iniguez, along with (A#1), toured the premises. (6) residents' rooms were selected at random for inspection, and LPA Iniguez observed that the rooms were maintained in a clean and orderly manner. On July 12, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed (PR#1)’s Service Agreement dated:8/23/2018. LPA Iniguez noticed that in the Service Agreement, it is written that part of the standard services provided by the facility are the following: Weekly linen laundry services and cleaning of apartments. Additionally, LPA Iniguez observed copies of the Facility Housekeeping schedule. LPA Iniguez noted that the schedule lists all residents’ rooms in the facility to be cleaned every week by the housekeeping department. On July 12, 2025, at approximately 10:00 AM, during an Interview with the Assistant Executive Director (A#1), he stated that their housekeeping department cleans the residents’ rooms; they are under the direction of the housekeeping director. Additionally, (A#1) stated that the housekeepers clean the residents’ rooms once a week, including (PR#1)’s rooms, as included in their service agreement. In case they need more, a service fee will be included as part of their care plan. Moreover, (A#1) stated that to his knowledge, housekeepers had never failed to clean (PR#1)’s room or any other resident in care. On July 12, 2025, at approximately 11:00 AM, LPA Iniguez was not able to spoke with (R#1) since they have passed away. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On July 12, 2025, at approximately 3:00 PM, LPA Iniguez was not able to connect with witness 1 (PW#1), tree attempts were made by the LPA. On July 12, 2025, at approximately 1:00 PM, during interviews with residents (R#2-R#9), (8) out of (9) stated that they like their rooms and they are clean. Also, (8) out of (9) stated that the housekeepers clean their rooms every week. On July 12, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that the housekeeping department is the one that cleans residents' rooms every week. Also, (4) out of (4) facility staff stated that (PR#1) 's room and other residents' care rooms got cleaned as scheduled. Allegation: Staff are not addressing pests at the facility. The details of the complaint alleged that (R#1)’s room had pests. On July 12, 2025, at approximately 2:00 PM, during a Health and Safety check of the facility, LPA Iniguez, along with (A#1), toured the premises. (6) residents' rooms were selected at random for inspection, and LPA Iniguez observed no signs of pests inside the residents' rooms. On July 12, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed copies from copies from pest control company invoices dated: 7/2024-5-2025, LPA Iniguez noticed that the company have been coming every month since July of 2024. On July 12, 2025, at approximately 10:00 AM, during an Interview with the Assistant Executive Director (A#1), he stated that the facility has a current contract with a pest control company that comes every month or as need it to the facility. Also, (A#1) stated that he has never seen pests in either (PR#1)’s room or any other resident in care room. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On July 12, 2025, at approximately 11:00 AM, LPA Iniguez was not able to spoke with (R#1) since they have passed away. On July 12, 2025, at approximately 3:00 PM, LPA Iniguez was not able to connect with witness 1 (PW#1), tree attempts were made by the LPA. On July 12, 2025, at approximately 1:00 PM, during interviews with residents (R#2-R#9), (8) out of (9) stated that they have not seen any pests inside their rooms. On July 12, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that they have seen the pest control company coming at the facility. Also, (4) out of (4) facility staff stated that they have not seen signs of pests inside the residents’ rooms. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Nathan Boese/Assistant Executive Director.

The department conducted interviews with staff #1-#5 (S1-S5) and residents #3-#10 (R3-R10) and was unable to interview R1-R2. Furthermore, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and common areas. The investigations revealed the following: Allegation: Staff are not ensuring residents’ showering needs are being met. It is being alleged that staff are not assisting residents with their bathing needs. On 07/12/25, between 11:00 AM and 12:00 PM the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff interviewed stated that residents are assisted with their showering needs based on their care plan. S1 stated that showers are in accordance with their care plan, and that on average most residents have shower/bathing assistance 1-2 times per week. On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R3-R10. Of those interviewed, 7 out of 8 residents stated they do not require assistance with showering, and 1 out of 8 residents said their showering needs are being met. 8 out of 8 residents stated that they don’t know if any residents have gone weeks without showering. 8 out of 8 residents said they are satisfied with the services provided to them. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are not providing adequate housekeeping services to residents. It is being alleged that resident’s room was observed to be filthy. On 07/12/25, between 11:00 AM and 12:00 PM, the department interviewed S1-S5. Of those interviewed, 5 out of 5 staff said staff is providing adequate housekeeping services to residents. 5 out of 5 staff said resident’s rooms are cleaned once a week, and as needed. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 07/12/25 between 01:30 PM and 02:35 PM, the department interviewed R1-R10. Of those interviewed, 8 out of 8 residents stated that their room is cleaned once a week. 8 out of 8 residents stated that they are satisfied with the services provided to them. On 07/12/25, the department and Nathan Boese toured the facility and inspected rooms A202, A212, A124, A129, B101, B201 and other common areas. The department observed the rooms and the facility to be clean and in sanitary condition. Based on observation, interviews conducted, and records reviewed, there is not sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. The department did not observe any deficiencies during this visit, therefore no citations were issued. An exit interview was conducted with Nathan Boese, and a copy of this report is provided.

On 06/28/25 from 8:45 am- 12pm LPA conducted Interviews with R2-11 regarding the allegation above, 8 of 10 residents interviewed denied the allegation above and reported they have not requested copies of their records but believe they facility would provide them upon request. 2 of 10 residents interviewed denied the the allegation above and reported they have received copies of their records when requested. On 06/28/25 LPA unable to interview R1 as R1 passed away while receiving services outside of Atria Hacienda. On 06/28/25 from 1:00 pm - 3:30pm LPA conducted interviews with S1-S8 regarding the allegation above, 7 of 8 staff interviewed denied the allegation above, 1 of 8 staff interviewed reported having no knowledge of records request. 3 of 8 staff interviewed reported copies of records are provided in person when requested, 1 of 8 staff reported copies of records are provided as requested, 4 of 8 staff interviewed are unaware of how records are provided. On 06/29/25 LPA conducted a review of R1’s file, LPA did not observe any records request documentation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.

and between 1pm and 3:30pm LPA conducted interviews with staff #2-9 (S2-S9). On 06/29/25 LPA conducted a review of R1’s and S1’s file. The investigation revealed the following: Allegation: Facility staff member functional forged residents’ signature. It is being alleged that facility staff forged residents’ signature for the facility to bill for a higher level of care. On 06/28/25 from 8:45 am- 12pm LPA conducted Interviews with R#2-11 regarding the allegation above, 10 of 10 residents denied the allegation above and reported feeling safe and comfortable when assisted by facility staff. On 06/28/25 between 1pm and 3:30pm LPA conducted interviews with S#2-9 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. On 06/28/25 LPA unable to interview S1 as S1 is no longer employed at Atria Hacienda. On 06/28/25 LPA unable to interview R1 as R1 passed away while receiving care outside of Atria Hacienda. On 06/27/25 LPA conducted telephone interview with Witness #1 (W1) regarding the allegation above, Per W1 an assessment was conducted on R1 on 11/30/22, the assessment resulted in a change from level 1 care to level 6 care which is a difference of $4500 in care charges. W1 continued to report that the signature on the assessment agreeing to the additional care fees is not R1’s signature. On 06/29/25 LPA conducted a review of R1’s file, LPA observed 7 service plan assessment conducted on 5/25/23, 4/15/23, 2/25/23, 1/25/23, 11/29/22, 11/1/22,10/16/2022. Per assessment conducted on 11/29/22, R1 level of care was a 3, LPA did not observe any signatures on the assessment document. Per assessment dated 11/29/22 it is indicated facility staff would coordinate with resident and family to assure that services are in place to maintain safety for resident while in care. Additionally, during file review LPA did not observe any documentation indicating that R1 had a conservator nor power of attorney. Per R1’s file R1 was self responsible. On 06/29/25 LPA conducted a review of S1’s file, LPA did not observe any corrective action documentation linked to the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.

Allegation: Facility billed resident for services not being provided. The allegation alleges that resident is being charged for services that are not being provided to the resident. LPA received and reviewed R2’s Physician’s Report (dated 09/21/2021) that indicates R2 is able to manage own medications. LPA received and reviewed a letter from the facility to R2’s physician (dated 06/09/2022) that indicates R2 is not compliant with managing own medications. Additionally, the letter indicates a care conference was conducted on 06/08/2022 with R2’s spouse and son regarding R2’s increase in falls, hospital visits, and medications not being refilled or picked up on time. LPA received and reviewed R2’s Needs and Service Plan (dated 09/09/2022) that indicates R2 receives stand-by assistance with transfers due to frequent falls, medication assistance with medication administration two (2) times a date. LPA observed billing statements are consistent with level of care R2 was receiving. Additionally, LPA received and reviewed the care plan and billing for three (3) residents and observed three (3) out of three (3) residents Care Plan and Billing Statement are consistent with services received. During interviews with Staff S1-S9, were asked if residents are paying for services they are not provided, nine (9) out of nine (9) stated no, residents do not pay for services they do not receive. During interviews with Residents R3-R11, were asked if they have been charged for services they do not receive, one (1) out of ten (10) stated they have been charged for services they do not receive. Additionally, the resident stated they took it to management and the charge was removed right away. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Business Office Director, Teresa Ramirez and a copy of this report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not assisting resident with their care needs. It is alleged that staff are not assisting Resident #1 (R1) with care needs. (R1) is visually impaired and struggles with making appointments and follow-ups for outpatient treatments. (R1) needs assistance but cannot afford this service. No further information is available on this matter. A review of Resident #1's (R1) Residency Agreement (dated 01/18/23) shows that (R1) was admitted to Atria Hacienda on February 04, 2023. Additionally, an examination of the Identification and Emergency Information document (dated 05/02/23) reveals that a power of attorney is designated to manage financial matters, care payments, and legal affairs on behalf of (R1). On November 06, 2023, between 09:45 AM and 11:58 AM, the Department interviewed a resident member identified as Resident #1 (R1). (R1) expressed concerns about challenges in making outpatient treatment appointments. (R1) mentioned that long call waits, scheduling issues, and staff shortages necessitated leaving messages. (R1) noted that a part-time private care staff member provides additional assistance with this task. On June 21, 2025, between 11:45 AM and 12:15 PM, the Department conducted a supplemental interview with Resident #1 (R1). (R1) expressed that the staff is attentive and responsive and treats (R1) well. (R1) mentioned that (R1)'s Care Plan designates a Care Level 1, which includes escort services due to (R1)'s visual impairment. (R1) confirmed having a private care staff member who comes once a week for four hours to assist with tasks involving reading emails, shopping online, and scheduling appointments with health professionals. (R1) stated that (R1) prefers to remain independent and will make medical appointments with the primary care providers. (R1) can complete this duty using a Braille calendar. (R1) stated that although (R1) prefers to schedule appointments with health providers, the facility care staff will assist with this task if (R1) needs assistance. On June 21, 2025, between 10:20 AM and 01:29 PM, the Department interviewed resident members identified as Resident #2 through Resident #10 (R2-R10). (R2-R10) resident members claimed to have no concerns or issues with their care needs. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Seven (7) out of the nine (9) residents member claimed to handle their own health appointments. (R2-R10) stated that facility care staff could assist if needed with this task. On November 06, 2023, and June 21, 2025, between 09:45 AM to 4:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not corroborate this claim. (S1-S5) reported that (R1) is independent and did not need help with medical appointments, only requiring minimal assistance like escort services. (S1) stated that the care staff was unaware of (R1)’s situation and would have gladly assisted if they had known as they understood (R1)’s limitations. On June 22, 2025, between 8:00 AM to 8:18 AM, the Department interviewed witness member identified as (R1)’s power of attorney as Witness #1 (W1). (W1) asserted that (R1) is independent, noting that (R1) is visually impaired, however can independently schedule health appointments. (W1) expressed confidence that the facility care staff provided adequate care and supervision with no concerns. As a result of record reviews of (R1)’s Physician’s Report LIC 624A (dated 01/23/23), Preplacement Appraisal LIC 603 (dated 01/29/23), Resident Functional Needs Service Plan (dated 02/04/23) verified that (R1) requires only escort services and is self-care independently. (R1) did not need special medical attention or incidental health and medical care assistance. A further review of facility Personnel Report LIC 500 (dated 11/06/23 and 06/13/25) revealed no shortage of care staff for AM, PM, and NOC shifts to assist with resident’s care needs. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview conducted with Resident Service Director Stephanie Roldan and copies of the report provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not prevent resident from harming other resident in care. It is alleged that staff did not prevent a resident from harming another resident in care. It is reported that Resident #2 (R2) was not prevented by staff from harming Resident #1 (R1). Additional details mentioned that (R1) was yelling and shouting from the resident’s room. It has been reported that (R2) has been seen squeezing (R1)’s arms and legs. No further information has been provided about this matter. A review of Resident #1 and Resident #2 (R1-R2)’s Residency Agreement (dated 10/28/22) shows that (R1 and R2) was admitted to Atria Hacienda on October 28, 2022, in a shared apartment. Furthermore, an examination of the Identification and Emergency Information LIC 601 (dated 02/02/23) shows that (R1 and R2) were given power of attorney to manage financial matters, care payments, and legal affairs. On June 20, 2023, and June 21, 2025, between 10:20 AM and 03:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not verify this claim. (S1-S6) reported that (R1) and (R2) shared an apartment and were considered companions and not legally married as spouses. (S2) mentioned witnessing (R2) squeeze (R1’s) arm and leg in frustration, prompting (S2) to intervene. (S2) clarified that this behavior did not constitute a physical assault on (R1) and did not result in any bruising or injury. Additionally, (S1-S5) stated that both individuals were heard or observed by care staff having verbal disagreements. There has never been any physical assault between them, and this fact is documented in their Resident Notes as staff have intervened as stated in reports. This evidence highlights that there is no violence in their interactions. (S5-S6) indicated that staff supervision is consistently adequate, and the facility utilizes surveillance cameras in common areas to enhance resident safety and effectively manage any incidents involving (R1 and R2). On June 21, 2025, between 10:20 AM and 01:29 PM, the Department interviewed resident members identified as Resident #3 through Resident #10 (R3-R10). (R3-R10) resident members reported they were unable to support this claim. Eight (8) out of the eight (8) resident members reported this is a well-maintained, well-supervised, and safe community, and they have not observed any physical aggression or verbal disputes among residents. On June 20, 2025, between 04:05 PM to 04:28 PM, the Department interviewed witness member identified as (R1)’s power of attorney Witness #1 (W1). (W1) explained that (R1 and R2) were companions. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (R1) lived in an apartment at Atria from October 2022 until July 2023, after which (R1) was transferred to Pacifica Nursing & Rehabilitation Center to receive a higher level of care. Unfortunately, (R1) passed away on September 17, 2023, due to health complications. (W1) mentioned having met (R2) multiple times and felt safe with (R2) as (R1) 's companion, stating that (W1) did not observe any violence between them. (W1) confirmed that (R1) never showed any physical injuries that required medical attention. While (W1) acknowledged that (R1 and R2) had verbal disagreements, as many couples do, (W1) noted no evidence of violence. (W1) also stated that (R1), due to (R1) 's health condition, often became confused and tended to embellish stories for attention. The Department could not interview Resident #1 (R1), and Resident #2 (R2) was unattainable on June 20, 2023, June 21, 2025, and June 22, 2025, as both residents had passed away. As a result of record reviews of (R1 and R2)’s Physician’s Report LIC 602 (dated 04/13/23,10/08/22, 09/30/22), Residency Agreement (dated 10/25/22), Identification and Emergency Information LIC 601 (dated 05/02/23), Resident Appraisal (dated 10/16/22 and 11/01/22), Resident Notes (dated 11/30/23 through 04/05/23, Internal Memo (dated 03/17/23) revealed that (R1 and R2) were companions and were medically assessed with no aggressive behaviors. A review of Resident Notes for (R1) indicated that the resident exhibited incoherence or distress. Further examination of (R1)’s Physician Medication Orders (dated 01/18/23) revealed that (11) out of the (14) prescribed medications had side effects that could lead to altered mental status (ref: National Institutes of Health, NIH). An additional review of facility Personnel Report LIC 500 (dated 06/2023 and 06/13/25) revealed no shortage of care staff for AM, PM, and NOC shifts to supervise residents in care.  During the June 21, 2025 visit, the Department identified that the facility promotes the rights of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. The surveillance cameras were conveniently located in common areas for observation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Resident Service Director Stephanie Roldan, and copies of the report were provided.

The investigation revealed the following: Allegation: Staff not providing adequate services The allegation alleges that there is not enough staff to provide adequate services to residents. During the facility tour, LPA observed four (4) caregivers and a Medication Technician (Med Tech) in the Memory Care Unit. LPA observed caregivers providing assistance to residents, a caregiver in common areas interacting with residents and supervising residents, and the Med Tech was passing afternoon medications. During record review at the facility, LPA reviewed the Time Detail Logs for 10/03/2021, on the AM shift there were seven (7) caregivers and four (4) Med Techs, on the PM shift there were six (6) caregivers and three (3) med techs, and on the NOC shift there were four (4) caregivers and two (2) med techs. LPA reviewed Staff Training Logs and observed staff receive training regarding Assisting With Activities of Daily Living (ADLs). Additionally, LPA received and reviewed Resident R1’s Service Plan dated 09/28/2021 that states R1 requires stand-by-assistance with all grooming two (2) times a day, complete assistance with dressing two (2) times a day, and complete assistance with showering and bathing two (2) times weekly, and assistance with toileting and incontinence six (6) times per day. During interviews with Staff S1-S5, on 06/21/25 from 2:30PM to 4:15PM, were asked if there is enough staff on each shift to meet resident needs, four (4) out of five (5) stated there is enough staff to meet resident needs. During interview with Resident R1 on 10/12/2021 and additional interviews with Residents R2-R10, on 06/21/25 from 10:20AM to 1:29PM, were asked if staff meet their care needs, ten (10) out of ten (10) stated their care needs are met. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Facility in disrepair. The allegation alleges that the facility is in disrepair. During the facility tour, LPA observed the facility to be clean and in good repair. During record review, LPA reviewed Work Orders that have been submitted and completed from 05/01/2025 to 06/22/2025. During interviews with Staff S1-S5, on 06/21/25 from 2:30PM to 4:15PM, were asked if there is anything not working properly or not working in the facility, five (5) out of five (5) stated everything is working properly in 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the facility. Additionally, Staff S1-S5, were asked if the facility is in disrepair, five (5) out of five (5) stated the facility is not in disrepair. Staff S1 and S5, during interviews were asked how long a repair takes once a Work Order has been put in, two (2) out of two (2) stated repairs are made within 24-hours unless a part is ordered and then will take at the most 72-hours for the repairs to be made. Additionally, Staff S1 and S2 stated if the repair cost is estimated $1000 or above, the repair must be approved by corporate before the repair is done. During interviews with Residents R2-R10, on 06/21/25 from 10:20AM to 1:29PM, were asked if there is anything in their rooms not working properly, eight (8) out of nine (9) stated everything is working properly in their room. Additionally, Residents R2-R10 were asked if the facility was in disrepair, nine (9) out of nine (9) stated the facility is not in disrepair. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . LPA did not observe or cite any deficiencies. An exit interview was conducted with Resident Service Director, Stephanie Roldan , and a copy of this report was provided.

During a subsequent visit conducted on 06/21/2025, LPA interviewed Staff S1-S5, interviewed Residents R1-R10, and received documents pertinent to the investigation. The following documents were received and reviewed an Administrator packet submitted on 06/06/2025 to Community Care Licensing (CCL). The investigation revealed the following: Allegation: Facility is without an Administrator The allegation alleges that the former Administrator left in April 2022 and there has not been a replacement. During the facility visit, LPA meet with the designated person listed on the Designation of Facility Responsibility (LIC308) while the current Administrator is on leave. During record review, LPA received and reviewed the following documents for the Administrators who are filling in while the current Administrator is on leave. The documents include the following forms: Application For A Community Care Facility or Residential Care Facility for the Elderly License (LI200) dated 06/04/2025 indicating an administrator change, letter informing (CCL) of the change dated 06/04/2025, Personnel Record (dated 06/01/2025), Health Screening (LIC503) dated 05/30/2025, copy of California Driver License, Criminal Record Statement & Out-of-State Disclosure (LIC508) dated 05/30/2020, Department of Social Services Clearance Background Check, dated 02/23/2023, Administrator Certificate valid till 03/24/2027, Designation of Facility Responsibility (LIC308), resume, college transcripts, First Aid certificate valid till 11/19/2026, an updated LIC500, and a copy of the mailing slip for the package to be sent. During interviews with Staff S1-S5, on 06/21/25 from 2:30PM to 4:15PM, were asked if the facility currently has an Administrator, five (5) out of five (5) stated yes, the facility has an administrator. During interviews with Residents R1-R9, on 06/21/2025 from 10:20AM to 1:29PM, were asked if the facility currently has an Administrator, ten (10) out of ten (10) stated yes, the facility has an Administrator and S1 is covering for the Administrator while they are out. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Resident Service Director, Stephanie Roldan , and a copy of this report was provided.

The witness informed LPA R1 resides at a skill nursing facility. This agency has investigated the complaint alleging the above allegations. Based on record review and interviews conducted all allegations are unfounded. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are mismanaging resident’s medications. It is alleged that the staff mismanaged Resident #1, #2, #3, and #4 (R1-R4) medications. According to reports, (R1) was given the wrong medication, which caused a decline in condition. Staff mismanaged (R2)’s narcotic patch, which caused a weak condition. (R3) and (R4) are prohibited from managing medications according to the care plan, but the staff was aware of this and allowed it. On September 9, 2024, April 24, 2025, and April 26, 2025, between 9:30 AM and 10:45 AM, the Department interviewed staff members designated as Staff #1 through Staff #4 and Staff #9 (S1-S4 and S9). Six (6) out of the six (6) staff members could not verify the allegation. (S1) indicated that no discontented residents or family members have complained about residents mismanaging medications. (S1 and S9) explained that resident medications are managed based on each resident's care plan. (S1) indicated that Resident #4 (R4) is independent and manages (R4)'s medications. Resident #1 (R1) managed (R1)'s medications until (R1)'s admission to hospice care on May 23, 2024. (S2-S4) verified there were no issues with resident’s (R1-R3) management of medications and that they followed the Seven Rights Rule: Right Person, Right Medication, Right Dose, Right Time, Right Route, Right Reason, and Right Documentation. Furthermore, if medication administration presented an issue with any residents, it would be documented in the Residents Notes and reported to Community Care Licensing (CCL). (S1-S4 and S9) confirmed that there have been no staffing shortages and that all Resident Medication Assistants (RMA) are cross-trained as Resident Service Assistants (RSA) to prevent staffing problems . Moreover, all care staff and med-techs have completed training in CPR and First Aid, medication management, and specialized areas such as cognitive care, fall prevention, communication, and basic caregiver skills. On April 26, 2025, between 10:35 AM and 12:25 PM, the Department interviewed resident members identified as Resident #4 through Resident #11 (R4-R11). Seven (7) out of the seven (7) resident members could not validate this allegation. (R4-R11) noted that they have no apprehensions or issues regarding medication management. (R4-R11) expressed their gratitude for the trained staff and their efficiency. On April 24, 2025, between 11:00 AM and 03:45 PM, the Department interviewed witness members identified as Witness #1 through Witness #7 (W1-W7).. (Evaluation Report continues LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Four (4) out of the four (4) family representatives claimed to have no issues with medication management by Atria staff and that residents (R1-R3) were under hospice care who also did oversee resident’s prescribed medications. Three (3) out of the (3) witness members identified as (W5-W7) hospice representatives verified (R1-R3) that all individuals were receiving hospice care with registered nurses working along with facility med-tech staff on medication administration. (W5-W7) reported no signs from hospice nurses that the resident in hospice care presented any medication management problems. The Department was unable to interview Resident #1 (R1) as (R1) passed away on July 1, 2024, while receiving hospice care from AHPC Palm Desert Inc. Resident #2 (R2) passed away on March 14, 2025, while under the care of Mission Hospice and was no longer a resident at Atria Hacienda. Resident #3 (R3), currently receiving care from Bella Terra Hospice and no longer a resident at Atria Hacienda, was interviewed but could not communicate due to health issues. The Department reviewed (R1-R4)’s Physician Report LIC 602A (dated 02/23/24, 05/23/24, 10/17/24 and 02/06/25) and Resident Functional Needs Care Plan (dated 08/16/23 through 07/17/24) confirmed (R1-R3) required assistance with medication management and (R4) is independent while (R1) remained to manage own medication until admission in hospice care on May 23, 2024. (R1-R4)’s Resident Notes, Resident Scheduled Task, and Medication Administration Record (dated 01/01/24 through 09/30/24) verified no documentation of the resident’s issues with medication administration. A review of staff-completed courses in the New Hire Medication Test, Medication Competency Test, and Medication Documentation revealed that staff have the skills and knowledge to perform their jobs well. Further review of the facility’s Personnel Report LIC 500 (dated 09/09/24 and 04/26/25) verified that (16) (RSA) staff for the morning shift, (12) (RSA) afternoon shift, and (13) (RSA) for the night shift and (2) (RMA) scheduled for each shift verification of no deficit of staff. On September 9, 2024, and April 26, 2025, the Department inspected the medication rooms thoroughly. The Department observed organized medications stored securely in carts accessible only to authorized personnel. Additionally, the Department observed that all medication administration records (MAR) are conveniently accessible electronically, enhancing efficiency and safety. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #3: Staff are not ensuring residents are showered. It is alleged that residents were not properly showered by the facility staff. It was reported that due to the staffing shortage residents were not being showered regularly. No further details have been provided concerning this allegation. On September 9, 2024, April 24, 2025, and April 26, 2025, between 9:30 AM and 10:45 AM, the Department interviewed staff members designated as Staff #1 through Staff #4 and Staff #9 (S1-S4 and S9). Six (6) out of the six (6) staff members could not corroborate the allegation. (S1) stated that they had not heard of any dissatisfied residents or family members complaining about residents not receiving showers. (S1 and S9) explained that showers for residents are based on each resident's care plan. (S1) noted that Residents #1 through #3 (R1-R3) were in hospice care and that hospice aides provided showers two to three times a week. However, (S2-S4) indicated if there had been instances where residents were not assisted with showers. They clarified that the Resident Notes would document a resident's refusal of the service. Additionally, they mentioned that residents who do not want a shower are offered a sponge bath instead. (S1-S4 and S9) verified that there have been no staffing shortages and that all Resident Medication Assistants (RMA) are cross-trained as Resident Service Assistants (RSA) to prevent staffing crises. (S2-S4) confirmed compliance with training requirements and completed basic training in caregiver skills courses. On April 26, 2025, between 10:35 AM and 04:15 PM, the Department interviewed resident members identified as Resident #4 through Resident #11 (R4-R11). Seven (7) out of the seven (7) resident members could not validate this allegation. (R4-R11) reported having no issues with personal care services. All were complimentary of the staff and stated they were responsive when assistance was needed. On April 24, 2025, between 11:00 AM and 03:45 PM, the Department interviewed witness members identified as Witness #1 through Witness #7 (W1-W7). Four (4) out of the four (4) family representatives claimed to have no issues with showering or bathing by Atria staff and that residents (R1-R3) were under hospice care. Three (3) out of the (3) witness members identified as (W5-W7) hospice representatives verified (R1-R3) that all individuals were receiving hospice services, and the hospice aides provided showers and bathing as part of the hospice care. (Evaluation Report continues LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Department was not able to interview Resident #1 (R1) as the resident passed away on July 01, 2024, while on hospice care with AHPC Palm Desert Inc. Resident #2 (R2) passed away on March 14, 2025, while on Mission Hospice and was no longer resident at Atria Hacienda. Resident #3 (R3), who is under Bella Terra Hospice and no longer resident at Atria Hacienda, was interviewed but could not converse due to the resident’s health condition. The Department reviewed (R1-R4)’s Physician Report LIC 602A (dated 02/23/24, 05/23/24, 10/17/24 and 02/06/25) and Resident Functional Needs Care Plan (dated 08/16/23 through 07/17/24) verified (R1-R3) needed assistance with bathing or showers while (R4) is independent. (R1-R4)’s Resident Notes and Resident Schedule Task (dated 01/01/24 through 09/30/24) verified no documentation of the resident’s issues with bathing or showers. A review of the Job Specific checklist revealed staff have completed courses in basic caregiver functions and duties. Further review of the facility’s Personnel Report LIC 500 (dated 09/09/24 and 04/26/25) verified that (16) (RSA) staff for the morning shift, (12) (RSA) afternoon shift, and (13) (RSA) for the night shift and (2) (RMA) scheduled for each shift verification of no shortage of staff. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #4: Staff are not meeting resident’s diapering needs. It is alleged that facility staff did not meet resident’s diapering needs. Due to the staffing shortage, residents were not being attended to with incontinence care in a timely manner. No further details have been provided concerning this allegation. On September 9, 2024, April 24, 2025, and April 26, 2025, between 9:30 AM and 10:45 AM, the Department interviewed staff members designated as Staff #1 through Staff #4 and S

Investigation Revealed the Following: Allegation: Resident is being held at the facility against their will. The details of the complaint alleged that (R#1) was held against their will at the facility. On April 27, 2025, at approximately 8:30 AM, during a records review, LPA Iniguez observed a copy of (R#1)'s Durable Power of Attorney, which was dated and sealed on June 6, 2014. The document listed (W#1) as the decision-maker for (R#1). Additionally, LPA Iniguez reviewed (R#1)’s Identification and Emergency Information form or LIC 601, dated February 28, 2023. This form identified (W#1) as the person responsible for (R#1)'s financial affairs, payment for care, and as (R#1)'s legal guardian. Furthermore, LPA Iniguez noted that (R#1)’s facility face sheet, printed on April 22, 2025, indicated that (R#1) has a Durable Power of Attorney on file, with (W#1) listed as the responsible party. LPA Iniguez also reviewed (R#1)’s Admissions Agreement, which was dated February 28, 2023, and noted that (W#1) signed this document on behalf of (R#1). On April 26, 2025, at approximately 8:30 AM, during an interview with the Administrator (A#1), she stated that when (R#1) moved into the facility, they had a Durable Power of Attorney designating (W#1) as their decision-maker. Additionally, (A#1) mentioned that (R#1) was not admitted under false pretenses and was not held against their will while residing at the facility. On April 24, 2025, at approximately 3:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez could not speak with (R#1) due to their cognitive impairment. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R#8), (7) out of (7) stated that they are not being held against their will and feel safe living here at the facility. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 9:00 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that that when (R#1) moved into the facility, they had a Durable Power of Attorney designating (W#1) as their decision-maker. Additionally, (4) out of (4) facility staff mentioned that (R#1) was not admitted under false pretenses and was not held against their will while residing at the facility. On April 24, 2025, at approximately 8:30 AM, Licensing Program Analyst Alfonso Iniguez spoke via telephone with (W#1), who resides out of state. LPA Iniguez introduced himself and explained that he was calling to ask questions regarding the complaint allegation related to (R#1). He inquired whether (R#1) had been placed at the facility against their will. (W#1) responded, “No, they were not” confirming that (R#1) was not placed at the facility against their will or under false pretenses. (W#1) explained that the decision to place (R#1) in the facility was made because they were unable to meet (R#1)'s medical needs. Furthermore, (W#1) indicated that they held Durable Power of Attorney for both healthcare and financial decisions for (R#1). During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Roldan/Resident Services Director.

Investigation Revealed the Following: Allegation: Staff are overcharging a resident for services not received. The details of the complaint alleged that facility staff is overhanging (R#1 and R#2) for services not received. On April 26, 2025, at approximately 2:00 PM, during a records review, LPA Iniguez observed that the admissions agreements for (R#1 and R#2), dated: September 21, 2022, included a clause under "Optional Services" stating, "We may also provide you with other Optional Services, if you request them, as described in Attachment F." This attachment outlines the optional services and associated fees. Additionally, LPA Iniguez noted that both (R#1 and R#2) had signed their admissions agreements on September 21, 2022. The LPA also reviewed the Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, dated September 19, 2022. It indicated that the primary diagnosis for (R#1 and R#2) was not a factor influencing their decision-making. Furthermore, the report marked that they were neither confused nor disoriented, could follow instructions, and were able to communicate their needs. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that (R#1 and R#2) signed their own admissions agreement upon entering the facility back on September 21, 2022. Also, (A#1) stated that the facility never overcharged (R#1 and R#2) for services not provided by the facility when they were living in here. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#3-R#9), (7) out of (7) stated that they had not been overcharged by the facility for services not provided to them. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) were not overcharged by the facility for services they did not receive. Allegation: Staff did not prevent the residents from wandering. The details of the complaint alleged that (R#1 and R#2) wandered out of the facility alone in the middle of the night. On April 26, 2025, at approximately 2:00 PM, LPA Iniguez conducted a records review and examined the Physicians Report for Residential Care Facilities for the Elderly (RCFE), known as LIC 602A, dated September 19, 2022. The report indicated that Residents #1 (R#1) and #2 (R#2) were neither confused nor disoriented, could follow instructions, and could communicate their needs. Additionally, it was noted that both residents were able to leave the facility unassisted. During the review, LPA Iniguez also looked at (R#1)’s Unusual Incident Report, which was dated June 18, 2024. The report stated that (R#1) was observed by facility staff outside the community at approximately 6:00 AM searching for (R#2). Staff promptly redirected (R#1) back inside, and an incident report was created with the appropriate parties notified. Moreover, LPA Iniguez reviewed facility staff training materials regarding elopement of residents, lates staff training was conducted on 4/14/25. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that neither (R#1 or R#2) wandered out by themselves in the middle of the night. Just the one incident when (R#1) was observed in front of the community looking for (R#2) at approximately 6:00 AM. Staff promptly re-directed them inside and documented this event on an LIC 624. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they feel the facility staff will handle an elopement of a resident in care. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1) did not wander out of the facility in the middle of the night, both stated that (R#1) was observed one time in front of the community but was promptly re-directed by facility staff. Allegation: Staff did not keep the facility free from scabies. The details of the complaint alleged that (R#1 and R#2) contracted scabies while at the facility. On April 26, 2025, at approximately 02:00 PM, during the records review, LPA Iniguez reviewed (R#1) and (R#2) entire files, LPA Iniguez did not observe medical records regarding (R#1 and R#2) had contracted scabies during their stay at the facility. In addition, LPA Iniguez observed the facility's infection control plan dated September 2021; it is stated that the facility has a plan in case of an infectious disease or outbreak. On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that (R#1 and R#2) did not contract scabies while they resided at the facility. On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they had never contracted scabies at the facility. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) never contracted scabies while they resided at the facility. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff unlawfully evicted the residents. The detail of the complaint alleges that facility staff gave an illegal eviction to (R#1 and R#2). On April 26, 2025, at approximately 2:00 PM, LPA Iniguez reviewed the records for (R#1 and R#2). During the review, LPA Iniguez found no eviction notices served to either (R#1 or R#2). Additionally, LPA Iniguez examined the Admissions Agreement contracts for both (R#1 and R#2), which were dated September 21, 2022. It was explained that a 30-day or 3-day notice may be issued if any written reasons outlined in the agreement apply to (R#1 or R#2). On April 26, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that the facility never gave an illegal eviction notice to (R#1 or R#2). On April 26, 2025, at approximately 10:00 AM, LPA Iniguez contacted former residents (R#1 and R#2) via telephone for the third time. They did not answer the call, so LPA Iniguez left a voice message. On April 26, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they had never received an illegal eviction notice from the facility. On April 26, 2025, at approximately 9:30 AM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that (R#1 and R#2) did not receive an illegal eviction notice from the facility. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Nathan Boese/Assistant Executive Director.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff are not providing adequate food service to residents. The complaint alleges that the facility staff is not providing adequate food services to residents. It has been reported that staff members were licking their fingers and touching the food served to residents. No further details have been provided concerning this allegation. On April 24 and April 26, 2025, between 09:30 AM and 10:45 AM, the Department interviewed staff members identified as Staff #1 and Staff #5 through Staff #9. (S1) and (S5-S9). Six (6) out of the six (6) staff members could not validate this allegation. (S1) stated they were not aware of any misconduct by food service staff regarding safe handling practices. (S5-S9) claimed safe handling practices for kitchen workers include regular handwashing, preventing cross-contamination, thorough cooking and reheating of food, and maintaining food at safe temperatures. They clean and sanitize surfaces and equipment frequently, store food properly, and be aware of fire safety. (S5-S9) claimed they are provided with a Waitstaff Job Specific Checklist, OSHA & Safety Training, and Food for Safety for Food Handlers training. (S5-S9) asserted that the waitstaff must wear appropriate clean uniforms, aprons, hair restraints, and gloves. Additionally, the information from (S5-S9) clarified that contaminants are carefully managed and never served to their residents in care. Ensuring their safety and well-being is their top priority. On April 26, 2025, between 10:35 AM and 04:15 PM, the Department interviewed resident members identified as Resident #4 through Resident #11 (R4-R11). Eight (8) out of the eight (8) resident members could not corroborate this allegation. (R5-R11) emphasized that they have consistently observed the kitchen staff practicing safe food handling. (R5-R11) praised the kitchen staff and servers as courteous, efficient, and providing excellent service. On April 24, 2025, between 11:00 AM and 03:45 PM, the Department interviewed witness members identified as Witness #1 through Witness #4 (W1-W4). Four (4) out of the four (4) family representatives claimed to have no issues with the food services provided by Atria Hacienda staff. (W1-W4) stated that during resident visits, they have never observed any violations of quality or safe food handling standards. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A review of the facility’s Weekly Menu (dated 09/06/24 through 09/14/24 and 04/27/25 through 05/03/25), Today’s Special Menu (dated 09/09/24 and 04/26/25), Waitstaff Job Specific Checklist & Training Topics, revealed staff have completed courses on OSHA & Safety, Food Safety, Kitchen Safety, Appearance Guidelines, Teamwork Guidelines, Customer Expectations and Special Diet Considerations. The Department conducted inspections on September 9, 2024, and April 26, 2025. The facility tour included a commercial kitchen, a dining terrace, two dining rooms, a bistro, and a bistro patio. During the inspection, the Department observed that kitchen staff were wearing gloves, hair restraints, aprons, and clean uniforms. The food supply was managed with appropriate dates to prevent spoilage and was stored at the correct temperatures according to Title 22 regulations. Moreover, the Department observed the presence of additional supplies of food thermometers, gloves, cleaning and sanitation supplies (like spray bottles and brushes), food preparation tools (such as cutting boards and labels), storage containers, and personal protective equipment (PPE), including aprons and masks. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is determined Unsubstantiated . An exit interview was conducted with Assistant Executive Director Nathan Boese, and copies of the reports were provided.

(Continued from LIC9099-A Page) R1 revealed they had paid the remaining balance on their account. LPA conducted (2) staff interviews which revealed R1 was given an eviction notice and served an Unlawful Detainer, which was dismissed due to R1 paying their remaining balance. (2) staff interviews revealed the facility is not currently pursuing an eviction with R1. This agency has investigated the complaint alleging “Illegal eviction” of R1. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC9099 page) LPA conducted (4) staff interviews. LPA conducted an interview with S1 who denied the allegations made, stating they did not threaten to lock R1 out of their unit or threaten R1 to sell their belongings and stating that they were accompanied by another staff member every time they spoke with R1. (2) of (4) staff interviewed had no knowledge of S1 threatening R1, while (1) of (4) staff revealed they accompanied S1 when they spoke to R1 and did not witness S1 threaten R1. Therefore, the allegation that R1 was threatened by staff is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

On 9/16/24 Licensing Program Analyst's (LPAs) Valerie Flores and Abdoulaye Zerbo conducted an unannounced one (1) year required visit. LPA's were greeted by the Executive Director, Monique Moreria, who was informed of the purpose of visit. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA's observed the following during today's visit: LPA's conducted a tour of the facility with Executive Director, Monique. The physical plant is a two-story structure that contains a total of 168 residents. While conducting the tour, LPA's observed all indoor and outdoor passageways were free of obstruction. The facility pool was gated and equipped with a self-latching door. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the locked kitchen areas making it inaccessible to the residents in care. There was a sufficient supply of emergency food and water to meet all resident needs. Water temperature measured at 113.5-degree Fahrenheit meeting within the required limits. Resident bedrooms had the required bedding, furniture, and lighting. LPA's observed charged fire extinguishers mounted throughout the facility. LPA's observed an outdoor courtyard with a shaded seating area and sufficient space to allow outdoor activities. The facility is maintained at 77 degrees-Fahrenheit for the resident’s comfort. There is a posted activity plan for the whole month of September to encourage resident interaction. The facility has a designated computer room that maintain computers connected to internet easily accessible to the residents in care. LPA reviewed the facility's infection control plan which met department requirements. There are several centrally stored medication rooms located throughout the facility. A sufficient amount of PPE was observed in the locked medication room. (Continuation on LIC809C...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff files reviewed have a criminal record clearance/ exemptions, valid first aid/CPR certification, health screenings, TB results, employee rights, and required trainings. Resident files included but are not limited to signed admission agreements, pre-appraisals, appraisals, physicians reports, TB tests, and personal rights. Facility sketch, personal rights, LTCO and emergency disaster plan is posted on a wall near the theater. According to Administrator, Monique, there are no firearms or ammunition on the premises. During today's visit, LPA's did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to the Administrator.

Administrator Moreira added R1 and R2’s family were kindly asked to step outside. Administrator Moreira reported law enforcement was called and issued Trespass Arrest Authorizations for three (3) of R1 and R2’s family members, including R1 and R2’s responsible person. LPA contacted law enforcement and verified the three (3) Trespass Arrest Authorizations are valid. LPA made several attempts to contact the reporting party and did not receive a response. R1 and R2 have since been relocated and were unable to be located for an interview. LPA interviewed one (1) resident who was identified as a possible witness. The resident corroborated witnessing R1 and R2’s family yelling profanities and behaving hostile towards Administrator Moreira and others around them. The resident reported they also asked R1 and R2's family to step outside to calm down and was yelled at by them. Based on the aforementioned, this agency has investigated the complaint alleging, “Staff are denying authorized representative access to the facility”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided Administrator Moreira.

On 10/06/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20231003091855 and to check on the health, safety, and welfare of residents in care. LPA met with Assistant Executive Director, April Princesa and explained the purpose of the visit. During the visit, LPA toured the facility and observed no health and/or safety hazards . LPA interviewed staff and residents, reviewed resident #2 (R2) file and collected copied of pertinent documents. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to April Princesa.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred fifty-nine (159) residents live at this facility. There are ninety-six (96) staff members present. The Assistant Executive Director, April Princesa conducted the tour and the Senior Executive Director, Robert Stansbury completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Five (5) record were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. (Continued on LIC809C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continuation from LIC809) Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 78 degrees for the resident’s comfort. Lighting is sufficient for safety. Water temperature measured at 108.0 degrees F. Laundry is done in the designated laundry room. The housekeeper supplies the detergent and cleaning supplies. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is not a fireplace at this facility. There is a pool at the facility that is surrounded by a 5-foot gate and lock. Each resident has a key to unlock and access the pool. The facility had their last annual fire inspection by the Desert Fire Inspection on 03/14/2023. LPA reviewed the facility’s last disaster drills, which met the department's requirements. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. (Continued on LIC809C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continuation from LIC809) Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked pushcart allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The fire extinguishers throughout the facility were last serviced and tagged on March 14, 2023. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Senior Executive Director, Robert Stansbury.

(CONTINUED FROM LIC9099 PAGE 1) Facility staff reviewed the assessments on each date mentioned with R1 however R1 did not sign the assessments at the discretion of the POA (for medical only) advice. R1’s inability to self-manage personal needs and resident expectations which must be followed to reside at the facility. Facility documentation reviewed and interviews revealed R1 and R2 is aware of the changes in Level of Care that R1 needs. This agency has investigated the complaint alleging "unlawful eviction". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names list.

(CONTINUED FROM LIC9099) anyone to make medical or other health care decisions for R1. Interviews conducted with facility staff and R1 revealed staff discussed R1's change in condition directly with R1. Regarding the allegation "Resident is being illegally evicted", it was alleged that R1 had back charges that had been paid but was still served with eviction notices. Review of R1's facility file did not yield any evidence that an eviction notice was served to R1. During interview with R1, R1 denied receiving an eviction notice. Regarding the allegation "Facility staff is not following resident's authorized care plan", it was alleged that R1 had a change in condition which resulted in a higher level of plan of care which was not authorized by R1's Power of Attorney. Review of R1's file including their admission agreement dated 10/18/2022 revealed R1 is responsible for themselves. R1's admitting Physician's report dated 10/25/2022 revealed R1 was not confused or disoriented, able to follow directions, able to communicate their needs, able to manage their own cash resources, and did not have a diagnosis of dementia or any cognitive impairment. Review of R1's Durable Power of Attorney (DPOA) for Financial Management dated 12/10/2022 revealed R1 has granted a close family member the power to manage, dispose of, sell, and convey their real and personal property, and to use their personal property as security if the DPOA borrows money on behalf of R1. The DPOA specifically indicates that the DPOA does not authorize anyone to make medical or other health care decisions for R1. Regarding the allegation " Facility staff bullied resident", it was alleged that R1 did not sign their own Functional Needs Service Plan at level 6 and facility staff bullied R1 into believing they did so. Interview with R1 revealed they did sign the level 6 plan and denied being or feeling bullied in doing so. Records with R1's signature including DPOA, admission agreement, and previous Functional Needs Service Plans revealed similar signatures. A signature provided to LPA and facility staff by R1 was also similarly consistent as well. This agency has investigated the complaint alleging " Facility staff did not notify resident's responsible party of a change in resident's condition", " Resident is being illegally evicted", Facility staff is not following resident's authorized care plan", and " Facility staff bullied resident". We have found that the allegations were unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

For allegation, Staff neglect resulted in resident falling and sustaining unknown injury: During document review, LPA found that on 6/22/2020 R1 fell on the floor by tripping over R1’s walker. The facility assisted R1, immediately called 911, and R1 was transported to the hospital. Based on the information found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Billing Director Yorlenis “Leni” Cota, along with a copy of the appeal rights.

On November 17, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Health and Safety visit. LPA Mixson was greeted and granted entry by Sabrina Tucker, Senior Executive Director and explained the purpose of the visit. LPA Mixson interviewed Executive Director and requested and received pertinent documentation. LPA Mixson toured the facility inside and out. At the time of the visit there were 143 residents and 80 facility staff. There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. All daily activities were going forth as usual without interruption. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply as well. LPA Mixson inquired about the supervision and/or assessment of residents for future concerns or issues or occarance. Director stated that all residents within the independent care units received three status checks per day. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin waited for the Executive Director for 45 minutes in order to go over the facility's Mitigation Plan/Infection Control Plan. LPA Colvin was finally met by Executive Director Sabrina Tucker and Assistant Executive Director April and toured the necessary areas of the facility to ensure infection control is being observed. Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Sabrina and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Sabrina Tucker. l in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Administrator Sabrina Tucker confirmed that all staff have been fit tested, and that they will be re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Sabrina Tucker confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin confirmed Administrator Packet has been received by Licensing and will be processed. An exit interview was conducted with Business Office Manager Tammy Eddy and a copy of this report was provided.

(CONTINUED FROM LIC 812) Five (5) of five (5) individuals interviewed stated they had not abused R1 or observed anyone abusing R1, nor had they heard of anyone abusing R1. The investigation revealed the injuries may have occurred during transferring R1. R1 was unable to be interviewed. The above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted with Assistant to the Business Office Manager Marianne Torres and a copy of this report along with LIC 811- Confidential Names list was provided.

Regarding allegation " Staff did not respond to resident's call button in a timely manner": LPA Colvin interviewed facility staff and reviewed facility call button response times. The response time log shows three pendant call for 3/8/22 (7:42pm, 7:46pm, & 7:55pm). The first two calls show response times in 3 minutes and 5 minutes, while the third pendant call shows response in 17 minutes. In reviewing the call log with the Assistant Executive Director and Care Service Director, it was unclear who responded to the first two calls, and all persons interviewed by LPA Colvin deny any staff attending to previous calls before the last call at 7:55pm (or knowledge of these calls occurring). The facility maintains a log for the staff pendants in order to identify who responded to each call, however, the pendant that was used on the first two calls had not been signed out for since 3/2/22. All interviews of parties involved maintain that no staff attended to R1 prior to the response to the 7:55pm call, wherein emergency services were called for R1 due to the fall and R1 hitting their head. Since there is conflicting information on when R1 first called for help after the fall and when staff responded, the allegation of "Staff did not respond to resident's call button in a timely manner" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Assistant Executive Director Monique Moreira and a copy of the report was provided.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a c opt of the report was provided. Due to technical issues with LPA Colvin's computer, a hand written report was left at the facility, and LPA Colvin maintains a copy with original signatures on file.

LPA Colvin additionally learned that housekeeping does not mix residents' linens and washes the linens for each room in its own cycle. Therefore, based on interviews, the allegation "Resident(s) are not provided with properly washed linens as needed" is UNSUBSTANTIATED. Regarding allegation "Facility surfaces are not properly sanitized by staff": LPA Colvin interviewed residents and staff members, as well as conducted a brief tour of some of the facility's common areas during today's inspection. LPA Colvin was informed that all common areas are cleaned daily by housekeeping with approved chemicals shown to sanitize surfaces and kill germs. LPA Colvin additionally observed the facility to be in good condition, with no observable stains, spills, or accumulated dirt/grime. Persons interviewed during today's inspection additionally informed LPA Colvin that they have no concerns with the cleanliness of the facility and have observed housekeeping to keep the areas clean. Therefore, based on observations and interviews, the allegation "Facility surfaces are not properly sanitized by staff" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Administrator Robert Barton and a copy of this report was provided.

Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit in regard to complaint investigation control number 18-AS-20200602112630. The purpose of this visit is to address possible additional information regarding the complaint investigation. During this visit LPA met with Executive Director Robert Barton. LPA and Mr. Barton further discussed hygiene assistance and documentation procedures. LPA was provided with facility census, R1's resident Functional Needs and Service Plan dated 04/29/2020, a sample of R1's resident monthly completed task for 04/29/2021, and resident notes for R1. Based on further record review and interview with Executive Director Robert Barton, LPA has found that the review of the information will not change the outcome of the delivered findings of the investigation for control number 18-AS-20200602112630. This report was reviewed with and a copy was provided to the facility representative.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:50 AM, LPA was met by Administrator Robert Barton and explained the purpose of the visit. Present in the facility during time of visit were fifty-six (56) staff as well as one hundred fifty-three (153) residents. 151 residents are fully vaccinated and 100 % staff are fully vaccinated. There are currently two cases of COVID-19 within the facility and quarantined. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed incomplete proper signage throughout the facility, minimum hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.

Based on interviews and record review the above allegation is UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed, and appeal rights were provided to Assistant Executive Director Victoria Mata, whose signature on this form confirm receipt of the above-mentioned documents.

Licensing Program Analyst (LPA), Pauline Beschorner conducted a case management visit to deliver an amended complaint investigation report regarding complaint number 18-AS-20200602112630. The report was reviewed with and provided to Assistant Executive Director Victoria Mata. Nothing further is needed at this time. An exit interview was conducted and a copy of this report was provided to Assistant Executive DIrector Robert Mata.

but R1 would not allow staff to wash R1's body. A review of documentation provided revealed that assistance with washing R1’s body was needed however there was no documentation of bathing refusals submitted to LPA. Staff interviewed stated that R1 was a very clean person and never smelled of perspiration or appeared dirty. The second allegation alleges resident did not have required emergency call button. Interviews with staff revealed that during the 2-hour checks the staff would ensure that the call button was within reach of R1. R1 always requested that the call button be placed to the right of R1's chair and on the nightstand to the right of R1's bed at night. S1, and S2 stated R1 misplaced the call button at times but staff would find it and place the call button back next to the chair or bed during the 2-hour checks. Staff interviews revealed R1 never used the call button and was very vocal about R1's needs and wants during the 2-hour checks. LPA was unable to corroborate that staff failed to provide the emergency call button. The third allegation alleges staff failed to follow resident's doctor's orders. A review of facility records indicates that R1 was to wear compression socks in the AM and take off in the PM. Interviews with staff indicated that R1 would put the compression socks on but would later take them off as the socks were uncomfortable to wear. There were times when R1 refused to put the socks on but there is no documentation of refusals by facility staff. LPA was unable to corroborate that staff failed to follow R1's doctor's orders. Although the above-mentioned allegations may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are deemed UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Assistant Executive Director Victoria Mata, whose signature on this form confirm receipt of the above-mentioned documents.

***Continued from 9099** Allegation #3: Facility staff is not assisting residents with ADLs. I nterviews and documentation review revealed that R1 is independent and does not require assistance with ADLs. R1's admission agreement indicates medication management and not assistance with ADLs. This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where the 9099, 9099C and LIC 811 were provided to Manny Salazar , Theresa Ramirez and Cheree Escandel via email.

Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted an unannounced case management visit to the facility for the purpose of delivering findings related to complaint number 18-AS-20200327111832. LPAs met with Tara Gonzalez, Resident Services Director. An exit interview was conducted with Miss Gonzalez and a copy of this report was provided.