374604717-1-14-2026-08-AS-SMAZ-DQSPNH-20260129102758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604717
Report Date: 01/14/2026
Date Signed: 01/14/2026 03:05:25 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
03/13/2024 and conducted by Evaluator Rebecca A Borunda

COMPLAINT CONTROL NUMBER: 08-AS-20240313162630

FACILITY NAME:	HACIENDA MISSION SAN LUIS REY, THE		FACILITY NUMBER:	374604717
ADMINISTRATOR:	BUHLE, DIANE		FACILITY TYPE:	740
ADDRESS:	4000 MISSION AVE		TELEPHONE:	(520) 797-4000
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	294	CENSUS: 197	DATE:	01/14/2026
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Executive Director Donna Daniel-Herr		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not ensure resident had access to meals
Resident was not accorded dignity with personal relationships
Licensee did not adminster medications as prescribed

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, interviewed staff, and reviewed and obtained copies of facility records. 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 Licensee did not ensure Resident 1 (R1) had access to meals, R1 was not accorded dignity with personal relationships, and Licensee did not administer medications as prescribed.

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 2

Control Number 08-AS-20240313162630

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

Interviews with residents did not reveal any concerns regarding the meals provided by the facility. Residents and staff stated that meals could also be delivered to resident rooms or picked up at the dining room, if residents wanted to eat in their apartments. Interviews with staff stated that if residents were observed to be feeling ill or seemed to be isolating in their apartments, staff would ensure that residents were eating and would order meals for delivery. Interviews with staff denied any concerns that any residents, including R1, were not eating meals. Review of R1’s assessment records dated 2023 and 2025 revealed that R1 was independent for most activities of daily living, including ensuring access to meals. Assessment records also stated that R1 occasionally required escorting to activities and meals if R1’s spouse was not present.

Multiple residents denied any concerns regarding staff interactions and stated that staff were pleasant, wonderful, and responsive to care needs and pendant calls. 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. Interviews with staff did not reveal any instances of staff responding to residents in a rude, disrespectful, or inappropriate manner, and staff stated that they would remove themselves from the situation to allow the resident to calm down. The Department did not obtain any evidence that the facility management were notified of any allegations of staff rudeness or disrespect.

Interviews with residents and staff and review of R1’s medical assessment dated 2023 and 2025 revealed that R1 did not have any cognitive impairment, was independent for most care needs, including medication administration, and was receiving assistance for showers multiple days a week. R1’s spouse also provided occasional assistance to R1, including escorting and medication management. Interviews and assessments revealed that the facility was not responsible for managing R1’s medications. Staff interviews revealed that all residents were reassessed every 6 months to ensure that residents’ care needs had not changed, and R1 was reassessed in late 2025, and remained independent for medication management. Interviews with staff did not reveal any concerns that R1 was not receiving their medications as prescribed or was not receiving appropriate level of care from R1’s spouse or facility staff.

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: 2 of 2