336400075-8-3-2025-18-AS-EMAZ-DKQRPT-20250820131228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336400075
Report Date: 08/03/2025
Date Signed: 08/03/2025 04:28:06 PM

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
10/03/2023 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231003091855

FACILITY NAME:	ATRIA HACIENDA		FACILITY NUMBER:	336400075
ADMINISTRATOR:	BARTON, ROBERT		FACILITY TYPE:	740
ADDRESS:	44600 MONTEREY AVE		TELEPHONE:	(760) 341-0890
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	266	CENSUS: 90	DATE:	08/03/2025
		UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Teresa Ramirez/Community Business Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was sexually assaulted while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 8/3/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Teresa Ramirez/Community Business Director. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of the department conducted the following interviews: Assistant Executive Director Interview (A#1), Witness Interview (W#1), Residents Interviews (R#1-R#2) and Staff Interview (S#1-S#2). The department obtained and reviewed the following documents: Resident Roster dated: 10/3/23, Staff Roster or LIC 500 dated: September/23, Riverside County Sheriff’s Department Report # T232650034 dated:9/22/23, Copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:12/14/22, Copy of (R#1)’s Preplacement Appraisal Information or LIC 603 dated:2/23/23.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2025

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 4

Control Number 18-AS-20231003091855

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: 08/03/2025

NARRATIVE

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

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20231003091855

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: 08/03/2025

NARRATIVE

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20231003091855

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: 08/03/2025

NARRATIVE

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.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4