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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336400075
Report Date: 06/29/2025
Date Signed: 06/29/2025 05:07:02 PM

Substantiated


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
01/18/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 18-AS-20240118104625
FACILITY NAME:ATRIA HACIENDAFACILITY NUMBER:
336400075
ADMINISTRATOR:ROBERT STANSBURYFACILITY TYPE:
740
ADDRESS:44600 MONTEREY AVETELEPHONE:
(760) 341-0890
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:266CENSUS: 181DATE:
06/29/2025
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not administer residents' medications as prescribed
INVESTIGATION FINDINGS:
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On 06/29/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Business Office Director, Teresa Ramirez, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
On 08/24/2022, LPA Delgado conducted an initial visit to the facility. During that visit, LPA Delgado interviewed Staff S1-S3 and Resident R1-R4
During a subsequent visit conducted on 06/28/2025, LPA Gibbs toured the facility, interviewed Staff S4-S14, interviewed Resident’s R5-R14, and received documents pertinent to the investigation. The following documents were received and reviewed Physician’s Report, Physician Orders, resident electronic Medication Administration Record (eMAR), Medication Summary, Staff Training Logs and Employee Corrective Action Form.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
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 7
Control Number 18-AS-20240118104625
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: 06/29/2025
NARRATIVE
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Allegation: Staff do not administer residents’ medication as prescribed
The allegation alleges that staff S2 are providing residents with their medication late or not at all.
During the facility tour, LPA conducted a medication review for ten (10) residents. LPA reviewed medication orders, eMAR, and the resident’s medication. LPA observed ten (10) out of ten (10) resident’s medications are consistent with properly documented records.
During file review, LPA received and reviewed ten (10) resident Med Summary for the month of June for the C Wing and observed S2 provided R16 their 06/15/2025 5PM medications at 7:08PM, on 06/22/2025 5PM medications were provided at 6:43PM, on 06/23/2025 5PM medications were provided at 8:10PM, and on 06/24/2025 5PM medications were provided at 11:16PM. No notes were in the system as to why the medication was provided late. Staff S2 provided Resident R17 their 06/02/2025 8PM medications were provided at 9:39PM, 06/04/2025 8PM medications were provided at 9:58PM, on 06/08/2025 8PM medications were provided at 9:11PM, 06/09/2025 8PM medications were provided at 9:15PM, on 06/10/2025 8PM medications were provided at 9:06PM, and on 06/11/2025 8PM medications were provided at 9:34PM. LPA did not observe any notes about why the medication was provided late. S2 provided R18 their 06/25/2025 7PM medication was provided at 8:21PM, with no notes indicating why medications were provided late. S2 provided R18 their 06/02/2025 4PM medications were provided at 5:17PM, 06/11/2025 5PM medication was provided at 6:57PM, 06/12/2025 5PM medications at 7:04PM, and on 06/18/2025 5PM medications were provided at 9:25PM. No notes were observed indicating why the medications were provided late. S2 provided R19 their 06/01/2025 8PM medications were provided at 9:12PM, 06/02/2025 8PM medications were provided at 9:14PM, 06/16/2025 8PM medications were provided at 9:11PM, 06/21/2025 6PM medications were provided at 7:49PM, 06/22/2025 8PM medications were provided at 9:15PM, 06/24/2025 8PM medications were provided at 9:46PM, and 06/27/2025 6PM medication was provided at 7:31PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R20 their 06/02/2025 5PM medications were provided at 6:23PM and on 06/04/2025 5PM medications were provided at 7:58PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R21 their 06/01/2025 7PM medications were provided at 8:24PM, 06/05/2025 7PM medications were provided at 8:16PM, 06/06/2025, 5PM medications were provided at 7:55PM, 06/13/2025 5PM medications were provided at 7:31PM, 06/15/2026 7PM medications were provided at 8:11PM, 06/18/2025 7PM medications were provided at 8:27PM, and 06/21/2025 7PM medication was provided at 8:24PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R5 their 06/04/2025 6PM medications were provided at 9:23PM, 06/07/2024 4PM medications were provided at 7:13PM, 06/14/2025
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20240118104625
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: 06/29/2025
NARRATIVE
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4PM medications were provided at 6:44PM, and 06/17/2025 6PM medication was provided at 7:10PM. LPA did not observe any notes indicating why medications were provided late. LPA observed seven (7) out of ten (10) residents were provided with their medications either late or early.
Additionally, LPA receuved and reviewed Employee Corrective Action Form Written Warning for a former Med Tech who on 05/14/2023, provided a resident with their afternoon medication and did not document it properly resulting in the resident receiving the medication twice. LPA received and reviewed an Employee Corrective Action Termination for a former Med Tech for an incident that occurred on 01/10/2024, where the Med Tech left at the end of their shift not informing management that the oncoming shift had not arrived, and 19 residents did not receive their medications.
During interviews with Staff S4-14, were asked if residents are provided with medication as prescribed, six (6) out of ten (10) stated residents are provided medications as prescribed. Additionally, four (4) out of ten (10) stated they have reported S2 for not providing medications on time or as prescribed and nothing has been done.
During interviews with Residents R5-R14, were asked if they receive their medications as prescribed, four (4) out of ten (10), stated they receive their medications as prescribed and six (6) do not receive assistance.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.


An exit interview was conducted with Business Office Director, Teresa Ramirez, and a copy of this report and the appeals rights was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20240118104625
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2(a) In addition to rights listed in section 87468.1, Persoanl Rights of Reisdents in all Facilities, residents in privately operated residental care facilities for the elderly shall have all the following rights: (4) to care, supervision, and services that meet their individual needs and are
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Administrator will develop a plan to ensure residents receive medications as perscribed and training for med tech's by the POC due date. Administrator will email LPA a copy of the plan developed and training logs.
Wendy.Gibbs@dss.ca.gove
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delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation was not met based on interview and record review, Staff S2 provided residents their medication late,this poses a health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
01/18/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 18-AS-20240118104625

FACILITY NAME:ATRIA HACIENDAFACILITY NUMBER:
336400075
ADMINISTRATOR:ROBERT STANSBURYFACILITY TYPE:
740
ADDRESS:44600 MONTEREY AVETELEPHONE:
(760) 341-0890
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:266CENSUS: 181DATE:
06/29/2025
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Teresa RamirezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff dispense medications to residents without a prescription
Residents wandered away from facility due to lack of supervision
INVESTIGATION FINDINGS:
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On 06/29/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Business Office Director, Teresa Ramirez, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
On 08/24/2022, LPA Delgado conducted an initial visit to the facility. During that visit, LPA Delgado interviewed Staff S1-S3 and Resident R1-R4
During a subsequent visit conducted on 06/28/2025, LPA Gibbs toured the facility, interviewed Staff S4-S14, interviewed Resident’s R5-R14, and received documents pertinent to the investigation. The following documents were received and reviewed Physician’s Report, Physician Orders, resident electronic Medication Administration Record (eMAR), Medication Summary, and Employee Corrective Action Form.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20240118104625
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: 06/29/2025
NARRATIVE
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Allegation: Staff dispense medications to residents without a prescription
The allegation alleges that staff dispense medications to residents that there is not a prescription for.

During the facility tour, LPA conducted a medication review that consisted of reviewing resident medication orders, the eMAR, and residents centrally stored medications for ten (10) residents. LPA observed ten (10) out of ten (10) centrally stored medications have a prescription order from the physician.


During interviews with Staff S4-S14, were asked if residents are provided medications without a prescription, ten (10) out of ten (10) stated residents are not provided medications without a prescription.
During interviews with residents R5-R14, were asked if they received medications that are not prescribed to them, four (4) out of ten (10) stated they are not given medication that are not prescribed to them, and six (6) of the residents do not receive medication assistance.

Allegation: Resident wandered away from the facility due to lack of supervision


The allegation alleges that a resident wandered away from the facility due to lack of supervision from staff.

During the facility tour, LPA observed staff in common areas interacting with residents. LPA observed staff providing escort service to residents, ensuring residents make it to their destination safely. LPA observed staff in the common areas in the Memory Care Unit providing supervision and activities.


During file review, LPA received and reviewed an incident report dated 08/21/2024 for R15, who was observed by staff, exiting out of a perimeter door. Staff asked R15 where they were going and R15 responded they were looking for their spouse. LPA reviewed R15’s Physician’s Report dated 07/26/2023, that indicates R15 has a diagnosis of Dementia and has a behavior of wandering and is at risk if allowed to leave the community unsupervised. LPA received and reviewed the Charting Notes for R15 that indicates R2 was moved from the assisted living unit to the memory care unit on 02/26/2024. Prior to moving into the memory care unit R2 was living in the assisted living unit with their spouse.
During interviews with Staff S4-S14, were asked if they feel there is adequate staff to supervise residents, ten (10) out of ten (10) stated yes there is enough staff to provide supervision for residents. Staff S8-S12 stated residents who have spouses in other parts of the facility are either taken to that part of the facility to be with their spouse or their spouse is brought to them. Additionally, Staff S4-S14 were asked if there have been any incidents of elopement in the past year, four (4) out of ten (10) stated there has been an incident of elopement from the memory care unit where a resident exited and staff followed them to the parking lot.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20240118104625
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: 06/29/2025
NARRATIVE
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During interviews with Residents R5-R14, were asked if there is adequate staff to supervise residents, ten (10) out of ten (10), stated yes they believe there is enough staff to supervise residents.

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.

An exit interview was conducted with Business Office Director, Teresa Ramirez, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7