The Hacienda Mission San Luis Rey

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

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 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).the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 08-AS-20240313162630

Allegation investigated: 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

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 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... 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). 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).the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 08-AS-20250808155713

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management to continue the annual inspection started on 9/9/2025. The facility file was reviewed prior to the visit. LPA identified herself to and explained the purpose of the visit with Executive Director (ED) Mariano Perez. The facility has a licensed capacity of 294 residents, 250 non-ambulatory, 12 bedridden and has a hospice waiver for 25 residents. During today’s visit, the facility had a census of 205 residents. The Administrator for the facility is Mariano Perez and their certificate was valid and current. During visits on 9/9/2025 and 10/22/2025, LPA inspected a random sampling of resident rooms and bathrooms, common areas, kitchen, and outside space. Secured perimeter was not observed on the premises. Facility had approved delayed egress in the facility's memory care and facility swimming pool was secured by a locked fence. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Mariano Perez, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility during the time of the inspection had a criminal background clearance and association. LPA reviewed multiple resident and staff records. LPA was away from the facility from 12:50pm to 1:50pm. No deficiencies were cited on today’s date. An exit interview was conducted with ED Mariano Perez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Director Carri Collins. During today's visit, LPA observed residents in care and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. An exit interview was conducted with Executive Director Mariano Perez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 9, 2025

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Move-In Coordinator Shelley Larkin. LPA also spoke with Executive Director Mariano Perez during the visit. During today’s visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed staff. LPA was away from the facility for approximately one hour between 12:30pm and 1:30pm. The Department's investigation consisted of interviews with residents and staff, records review, and a tour of the facility. It was alleged that the licensee unlawfully evicted Residents 1 and 2 (R1 and R2). Interviews with staff and R1, as well as review of R1 and R2's admission agreement signed May 2025 revealed that R1 and R2 moved into the facility on 5/15/2025 under a respite stay of approximately one month. Continued on LIC9099-C page... Substantiated Interviews with staff revealed that facility management received multiple complaints from residents and staff regarding R1 and R2's behavior and comments. Interviews with staff revealed that R1 and R2 made multiple comments that residents felt were inappropriate, abrasive, and judgmental. Interviews with staff and R1 revealed that on 5/26/2025, the Executive Director spoke with R1 and R2 regarding their behavior and stated that their respite stay would need to be shortened and that R1 and R2 would need to leave the facility. Review of R1 and R2's admission agreement signed May 2025 revealed that residents could only be evicted from the facility via a written 30-day notice or a written 3-day notice with prior Department approval. The Executive Director confirmed in interviews that a written 30-day notice was not issued to R1 or R2 at any time. Review of documents received by the Department from the facility confirmed that a 3-day eviction notice was also not requested. Interviews confirmed that R1 and R2 vacated their apartment on 5/26/2025. The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency was cited for unlawful eviction and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Mariano Perez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). Interviews with staff and R1 and review of R1 and R2’s admission agreement signed May 2025 revealed that R1 and R2 moved into the facility on 5/15/2025 under a respite stay for approximately one month. Interviews with staff and R1 and review of R1 and R2’s fee schedule paperwork revealed that the daily rate for R1 and R2’s stay at the facility was $350, for a total of $10,500 for the month-long stay. R1 and R2 paid a deposit of $2,500 via check for their respite stay in April 2025 and paid $8,500 via check on 5/15/2025. Interviews with staff and R1 revealed that the amount on the second check was written incorrectly and R1 and R2 did not have a spare check to fill out at that time, therefore, R1 and R2 paid a total of $11,000 and had overpaid for their 30-day respite stay by $500. Interviews with R1 and staff did not reveal that R1 and R2 unknowingly overpaid upon move in and confirmed that there were discussions that R1 and R2’s stay could be extended, or the extra money would be refunded at a later date. On 5/26/2025, R1 and R2 were asked to move out of the facility by the Executive Director and they vacated their apartment on the same day, terminating the admission agreement. This resulted in R1 and R2’s stay only consisting of 12 days from 5/15/2025 to 5/26/2025. Review of R1 and R2’s admission agreement revealed that the facility’s refund policy stated that any prepaid unused fees minus any expenses incurred by the facility to repair or replace damaged property and remove or store any belongings left behind would be refunded within 30 calendar days of the termination of the agreement. Interviews with staff and R1 revealed that R1 and R2 received a full refund of the total $11,000 paid to the facility 15 days later, on 6/10/2025. The Department has investigated the above-mentioned allegation and based on interviews and records review, this allegation is deemed unfounded, meaning that the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted with Executive Director Mariano Perez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 08-AS-20250603135425

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jul 11, 2025

87224 Eviction Procedures (a) The licensee may evict a resident... Thirty (30) days written notice to the resident is required... This requirement has not been met as evidenced by: Based on interviews and record review, the Licensee did not comply with the section cited above in that R1 and R2 were verbally evicted from the facility. This poses a potential personal rights risk to 182 of 182 residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2025

Plan of correction: Executive Director and Resident Care Director will receive eviction training and provide proof of training to the Department by POC due date of 7/11/2025.

Allegation investigated: Staff did not ensure that resident received phone calls

Licensing Program Analyst (LPA) Rebecca Ruiz 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 Memory Care Director Bianca Tapia. During today’s visit, LPA observed residents in care, obtained copies of facility records, 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 ensure that resident received phone calls, specifically Resident 1 (R1). Review of R1’s physician report dated October 2023 revealed that R1 had a diagnosis of major cognitive impairment and was confused and disoriented, but was able to follow directions and communicate needs. Continued on LIC9099-C page... Unsubstantiated Review of R1’s assessment records dated November 2024 revealed that R1 was able to answer phone calls independently but was unable to make calls or remember phone numbers and required staff assistance to make phone calls. Interviews with staff revealed that some residents would ask to make a phone call or would request staff assistance to make phone calls. If residents were unable to make phone calls independently, did not have a personal cell phone or land line, or did not recall the number of the person the resident wanted to speak with, staff would assist residents to make phone calls using the telephone located in the medication room. Interviews with staff also revealed that the phone in the medication room was available for residents to use without staff assistance. Interviews with staff and outside sources revealed that outside individuals would call the medication room and would request to speak with residents. If the resident was unavailable due to participating in activities and meals, asleep, or out in the community, staff informed the individual that the resident was unavailable and would pass along the message that the individual had called to speak with the resident. Interviews revealed that staff would give the resident a note stating that the individual called and asked the resident to call the individual. Interviews with staff revealed that R1 had a personal telephone that was set up by R1’s responsible person and R1 used it to make telephone calls independently. Additionally, interviews with staff revealed that R1 would occasionally ask to make phone calls using the phone in the medication room and staff would assist R1 with dialing the number. However, R1 would occasionally not know the number to the individual R1 was trying to reach and R1 was unable to complete the phone call. Interviews with staff revealed that on at least one occasion, R1 became agitated following a phone call with outside individuals. Interviews with residents, including R1, did not reveal any concerns regarding residents’ ability to maintain contact with outside individuals via telephone or during in-person visitation. Interviews with staff revealed that staff were aware of residents’ personal rights to visitation, making phone calls, and keeping in communication with family, friends, and outside individuals. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Resident Care Director Carri Collins, Memory Care Director Bianca Tapia, and Business Office Manager Kristine Gutierrez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 08-AS-20240906142829

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Annual Continuation visit to continue the annual inspection started on 7/22/2024. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Director Carri Collins. The facility is licensed for a maximum capacity of 294 residents, 250 of which may be non-ambulatory and 12 may be bedridden in any room. The facility has a waiver for 25 hospice residents. During today’s visit, the facility had a census of 142 residents. The Administrator for the facility is Mariano Perez and their certificate was valid and current. During visits on 7/22/24 and 8/1/24, LPA toured the facility and inspected a random sampling of resident rooms, common and private bathrooms, kitchen, common areas, and outside space. LPA observed a fenced pool in the assisted living portion of the facility which was secured by fencing and a locked gate which met regulation requirements. LPA observed delayed egress in the facility's memory care which matches the fire clearance approval. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 109.8, 110.7, 111.4, 111.7, 112.8, 113.0 and 113.8 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 71, 72, and 74 degrees Fahrenheit at different locations of the facility during the walk through. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Carri Collins, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 39 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. Continued on LIC809-C page… LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The Executive Director will submit copies of the LIC500 Personnel Report, LIC610 Disaster Plan, and current liability insurance to the Department within 15 business days. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Mariano Perez via telephone and Resident Care Director Carri Collins, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Aug 1, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding an elopement. LPA was greeted by, identified herself to, and explained the purpose of the visit with Business Office Manager Kristine Gutierrez. On 6/26/2024, the Department received a self-reported incident report that described an elopement that occurred on 6/25/2024. The incident report stated that Resident 1 (R1) had eloped from the facility and was found by law enforcement and had sustained injuries in the process of the elopement. The facility was notified of R1's elopement by law enforcement and sent staff to escort R1 to the hospital to receive medical treatment for R1's injuries. Facility staff notified R1's responsible party of the elopement. R1 returned to the facility on 6/27/2024. During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, and interviewed staff. R1 moved out of the community on 7/12/2024 and was not present during LPA's visit. LPA did not observe any health or safety concerns during the visit. At this time, additional follow-up is needed. No deficiencies were cited on today’s date. An exit interview was conducted with Business Office Manager Kristine Gutierrez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Business Office Manager Kristine Gutierrez. During today's visit, LPA toured the facility, reviewed facility records and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Business Office Manager Kristine Gutierrez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to the facility to conduct a collateral visit pertaining to a complaint for La Marea Senior Living. LPA Silveira identified herself, stated the purpose of the visit and was granted entry by Executive Director Mariano Perez. During the visit, LPA Silveira spoke briefly to the Executive Director and interviewed residents as relative to the investigation. No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Mariano at the conclusion of the visit. The signature below confirms the receipt of the documents.the state’s words, verbatim · CDSS document, May 23, 2024