<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604717
Report Date: 01/14/2026
Date Signed: 01/14/2026 03:04:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20250808155713
FACILITY NAME:HACIENDA MISSION SAN LUIS REY, THEFACILITY NUMBER:
374604717
ADMINISTRATOR:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:4000 MISSION AVETELEPHONE:
(520) 797-4000
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:294CENSUS: 197DATE:
01/14/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Executive Director Donna Daniel-HerrTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer medications as prescribed
Staff did not treat resident with dignity
Licensee did not provide residents with a 90 day written notice of rate increase
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Donna Daniel-Herr and Resident Care Director MariRose Kruger.

During today’s visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not administer medications as prescribed to Resident 1 (R1), that the Licensee did not provide residents with a written 90-day notice of rate increase, and staff did not treat resident with dignity.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
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 5
Control Number 08-AS-20250808155713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HACIENDA MISSION SAN LUIS REY, THE
FACILITY NUMBER: 374604717
VISIT DATE: 01/14/2026
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
Review of resident records revealed that some residents received a written 90-day notice in May 2025 which stated that the basic rate of service would be increase effective September 1, 2025, which was a notice period of over 90 days. Interviews with residents revealed that the facility issued rate increases annually, usually on the anniversary of the resident’s move in date and advance notice was provided via written notice. Those interviews also revealed that the notice was generally provided at least 3 months prior to the rate increase taking effect. Interviews with staff revealed that rate increases were assessed on the anniversary date of the resident’s move-in, which was supported by information provided by residents. Interviews with staff responsible for handling resident billing revealed that residents were notified of the annual rate increase via written letter that was placed in their mailbox at the facility. Staff did not provide any evidence that the written notices were provided to residents less than 90 days prior to the notice taking effect.

Interviews with staff and facility management revealed that facility policy stated that staff would try to encourage residents to take their medications multiple times before noting the resident refusal, and would also try having a different staff member administer the medication or provide care. Interviews with staff supported this policy and provided evidence that staff would attempt to provide care or administer medications to R1 multiple times. Interviews with staff reported some difficulty with providing care and administering medications for R1 due to R1’s occasional resistance to care. Staff reported that R1 would often refuse medications and care if the medication or care was not provided immediately when R1 wanted to receive the care. R1 stated during interviews that staff confused R1’s medications, however, R1 did not provide clarification on the confusion or if R1 had ever received incorrect medications. Facility progress notes for R1 revealed that R1 stated that they were refusing because they no longer needed that medication. Interviews with staff and review of facility communication to R1’s physician revealed that R1 refused to take multiple medications and supplements, including a heart medication. These communications revealed that R1’s physician agreed with discontinuing other medications that R1 refused but did not agree to discontinue R1’s heart medication. R1’s medication administration records for July and August supported interview evidence that R1 often refused medications.

Continued on LIC9099-C page...
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250808155713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HACIENDA MISSION SAN LUIS REY, THE
FACILITY NUMBER: 374604717
VISIT DATE: 01/14/2026
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
Multiple residents denied any concerns regarding staff interactions and stated that staff were pleasant, wonderful, and responsive to care needs. Some resident interviews did allege that staff were rude or disrespectful, however those interviews did not provide specific details on how staff were rude or disrespectful when asked to clarify. The Department was unable to obtain any information that facility management were notified of any allegations of staff rudeness or disrespect. Additionally, staff reported that some residents were occasionally difficult to provide care for due to impatience and inappropriate comments. Staff denied responding to any residents with anger and stated that they would leave and attempt to provide care after a short period of time to allow the resident to calm down.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Donna Daniel-Herr, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20250808155713

FACILITY NAME:HACIENDA MISSION SAN LUIS REY, THEFACILITY NUMBER:
374604717
ADMINISTRATOR:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:4000 MISSION AVETELEPHONE:
(520) 797-4000
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:294CENSUS: 197DATE:
01/14/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Executive Director Donna Daniel-HerrTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed a pressure injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Donna Daniel-Herr and Resident Care Director MariRose Kruger.

During today’s visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that Resident 1 (R1) developed a pressure injury while in care. Review of R1’s medical and care assessments from 2025 revealed that R1 required assistance with most activities of daily living, including two-person assistance for transferring, and was on a two-hour toileting schedule.
Continued on LIC9099-C page...
Unfounded
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250808155713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HACIENDA MISSION SAN LUIS REY, THE
FACILITY NUMBER: 374604717
VISIT DATE: 01/14/2026
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
Additionally, staff were instructed to conduct skin checks during incontinence and hygiene care. Staff reported some difficulty with providing care for R1 due to R1’s occasional resistance to care. Review of progress notes and staff interviews revealed that R1 developed a rash while in care, but the evidence collected did not support the allegation that the rash was an early pressure injury. Review of R1’s medication administration records showed that R1 would often refuse an ointment prescribed to treat their rash. Interviews with staff did not reveal any evidence that R1 developed a pressure injury at the facility and R1 denied the allegation that they developed a pressure injury while in care at the facility.

The Department has investigated the above-mentioned allegation and based on interviews and records review, it was determined that the complaint allegation is Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Executive Director Donna Daniel-Herr, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5