336426760-8-22-2023-18-AS-RSTS-CV8VCY-20230831161954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426760
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:50:13 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
08/14/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230814152020

FACILITY NAME:	HACIENDA SENIOR LIVING		FACILITY NUMBER:	336426760
ADMINISTRATOR:	MARLYA DUNHAM		FACILITY TYPE:	740
ADDRESS:	161 N HEMET ST		TELEPHONE:	(951) 927-6817
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	66	CENSUS: 18	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	11:53 AM
MET WITH:	Marlya Dunham, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff hit resident.
Staff threatened resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Marlya Dunham, and informed her of the purpose for her visit.

The investigation included staff/resident interviews, records review, and records collection.

An allegation was received by the Department alleging a facility staff member physically assaulted Resident One (R1) on or around August 13, 2023. R1 was interviewed and reported an unknown staff member hit them with a polled up piece of paper to the back of their head. Details of the alleged incident changed throughout the interview with R1. The Administrator was interviewed and reported she interviewed R1 who provided her with brief details of the alleged suspect, matching the description of Staff One (S1). S1 was interviewed and denied the allegation. Additional staff/resident interviews reported there is no knowledge of incidences in which staff have physically assaulted a resident in care. Therefore, due to insufficient information, this allegation is

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230814152020

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: HACIENDA SENIOR LIVING	FACILITY NUMBER: 336426760
	VISIT DATE: 08/22/2023

NARRATIVE

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deemed UNSUBSTANTIATED at this time.

In addition, it was reported a staff member threatened to throw R1 in jail. R1 was interviewed and reported an unknown staff member threatened the resident by stating, "next time I'm going to call the police". The resident could not provide any further details. The Administrator was interviewed and reported having no knowledge of R1 allegedly being threatened. Staff interviews reported there was no knowledge of residents being threatened. One resident interview reported R1 has physically assaulted staff in the past. It was reported staff have told R1 they would contact law enforcement if the resident hit staff again. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred.

This report was reviewed with Administrator Dunham and a copy was provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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