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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881151
Report Date: 05/22/2026
Date Signed: 05/22/2026 06:33:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/29/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231129141628
FACILITY NAME:HACIENDA LIVINGFACILITY NUMBER:
361881151
ADMINISTRATOR:VELAZQUEZ, RAULFACILITY TYPE:
740
ADDRESS:11412 TELEPHONE AVETELEPHONE:
(213) 440-4823
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 6DATE:
05/22/2026
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Raul VelazquezTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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9
Staff do not ensure residents personal possessions are safeguarded at all times.
Staff do not speak to residents in an appropriate manner.
Licensee does not ensure all staff are able to communicate with residents in care.
INVESTIGATION FINDINGS:
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5
6
7
8
9
10
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13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the complaint investigation on the above allegations. LPA identified self and met with Administrator Raul Velazquez. The investigation consisted of LPA observation, reviewing pertinent records, and interviews with relevant parties.

Regarding the allegation, staff do not ensure residents personal possessions are safeguarded at all times, interviews with the Administrator, three (3) staff, and three (3) residents reveal that staff are ensuring residents personal possessions are safeguarded and no resident personal items have been reported missing. The facility has a theft and loss policy and bedroom doors that lock.

Regarding the allegation, staff do not speak to residents in an appropriate manner, interviews with the Administrator and three (3) staff reveal that staff do speak to residents in an appropriate manner.
**continued on LIC9099-C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
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 56-AS-20231129141628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
VISIT DATE: 05/22/2026
NARRATIVE
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Interviews with three(3) residents reveal that staff do speak to them in an appropriate manner.

Regarding the allegation, Licensee does not ensure all staff are able to communicate with residents in care, interviews with the Administrator, three (3) staff, and three (3) residents reveal that staff are able to communicate with residents in care and there are no language barriers.

Based on the Department's investigation the allegations mentioned in this report are Unsubstantiated. Unsubstantiated meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy provided to Administrator Velazquez at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/29/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231129141628

FACILITY NAME:HACIENDA LIVINGFACILITY NUMBER:
361881151
ADMINISTRATOR:VELAZQUEZ, RAULFACILITY TYPE:
740
ADDRESS:11412 TELEPHONE AVETELEPHONE:
(213) 440-4823
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 6DATE:
05/22/2026
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Raul VelazquezTIME COMPLETED:
06:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure medications are dispensed as prescribed to residents in care.
Staff do not ensure the medications are centrally stored and secured at all times for residents in care.
Staff do not ensure residents medication records are properly maintained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the complaint investigation on the above allegations. LPA identified self and met with Administrator Raul Velazquez. The investigation consisted of LPA observations, reviewing pertinent records, and interviews with relevant parties.

Regarding the allegation, staff do not ensure medications are dispensed as prescribed to residents in care, an audit of three (3) resident medications and medication orders, reveals that facility staff did not have one of resident #1 (R1's) prescribed daily medication on hand. Staff stated they assumed medication #1 had been discontinued since the pharmacy didn't deliver it to the facility. Staff stated that it has been a week since medication#1 was administered to R1.

***continued on LIC9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20231129141628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
VISIT DATE: 05/22/2026
NARRATIVE
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Regarding the allegation, staff do not ensure the medications are centrally stored and secured at all times for residents in care, LPA observed medications for residents being stored in an unlocked kitchen refrigerator.

Regarding the allegation, staff do not ensure residents medication records are properly maintained, review of three (3) resident medications records reveals that all three (3) residents take PRN medications. Staff stated that although the residents' PRN medication have been administered, there is no documented record of when the medication was taken, the dosage taken, and the resident's response.

Based on the Department's investigation, the allegations are Substantiated. A finding that the complaint is Substantiated means that the allegation(s) are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted. Copies of reports (LIC9099, LIC9099C & LIC9099-D) were provided with appeal rights to Administrator Velazquez at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20231129141628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2026
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical...The plan shall encourage routine medical... and provide for assistance in obtaining such care, by compliance with the following:(1)The licensee shall arrange, or assist in arranging, for medical appropriate to the conditions and needs of residents..this requirement is not met as evidenced by:
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The Licensee/Administrator stated that they will obtain R1's daily medication#1 by POC due date.
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The Licensee did not comply with the section cited above by Staff did not make appropriate arranges to obtain R1 prescribed medications resulting in R1 not having medications on hand; which poses an immediate health, safety, and personal rights risks to persons in care.
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Type A
05/25/2026
Section Cited
CCR
87465(h)(2)
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(h) The following...apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication; this requirement is not met as evidenced by:
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The Licensee/Administrator stated that the refrigerated medications will be placed in an appropriate locked container by POC due date.
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The licensee did not comply with the section cited above by LPA observed resident's medications stored unlocked in kitchen refrigerator; which poses an immedicate health, safety, and personal rights risks to persons in care.
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9
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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: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20231129141628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2026
Section Cited
HSC
87465(d)(3)
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(d)If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided; (3)The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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The Licensee shall provide staff training PRN medication management and submit documentation of training by POC due date.
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The Licensee did not comply with the section cited above by not maintaining a record of when all three (3) residents PRN medications were taken.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6