336400075-4-28-2025-18-AS-RORN-DG9PV3-20250501113829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336400075
Report Date: 04/27/2025
Date Signed: 04/28/2025 07:38:35 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240906082057

FACILITY NAME:	ATRIA HACIENDA		FACILITY NUMBER:	336400075
ADMINISTRATOR:	ROBERT STANSBURY		FACILITY TYPE:	740
ADDRESS:	44600 MONTEREY AVE		TELEPHONE:	(760) 341-0890
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	266	CENSUS: 70	DATE:	04/27/2025
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Stephanie Roldan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are mismanaging resident's medications.
Staff are not ensuring residents are showered.
Staff are not meeting resident's diapering needs.

INVESTIGATION FINDINGS:

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On April 27, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit to gather information regarding the above allegation. LPA met with Resident Services Director Stephanie Roldan , and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1, #5 to #9 (S1 and S5-S9), resident members #4 to #11 (R4-R11), and Witness members #1 to #7 (W1-W7). List of documents reviewed/obtained Resident Roster (dated 09/09/24 & 04/26/25), Staff Roster (dated 09/09/24 & 04/26/25), 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) and other documents pertinent with this complaint.

(Evaluation Report continues LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 18-AS-20240906082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 04/27/2025

NARRATIVE

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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)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 18-AS-20240906082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 04/27/2025

NARRATIVE

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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)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 18-AS-20240906082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 04/27/2025

NARRATIVE

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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.

(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)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 18-AS-20240906082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 04/27/2025

NARRATIVE

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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.

(Evaluation Report continues LIC 9099C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 18-AS-20240906082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 04/27/2025

NARRATIVE

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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) stated having no concerns or issues with incontinence care. (R4-R11) praised the staff, highlighting their responsiveness and willingness to assist whenever 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 incontinence care 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, the hospice aides and Atria (RSA) staff provided incontinence care; however, according to (W5-W7), there were no indications from hospice aides that the resident on hospice care had incontinence problems.

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 incontinence services (R4) is independent. (R1-R4)’s Resident Notes and Resident Scheduled Task (dated 01/01/24 through 09/30/24) verified no documentation of the resident’s issues with incontinence care. A review of the Job Specific checklist indicates that staff have completed essential courses in caregiving functions and responsibilities. Additional 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.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.

An exit interview was conducted with Stephanie Roldan, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2025

LIC9099 (FAS) - (06/04)

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