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)

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 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.