198600271-11-20-2025-28-AS-DSIS-DP2TSG-20251204135909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600271
Report Date: 11/20/2025
Date Signed: 11/20/2025 03:29:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250530103508

FACILITY NAME:	HAMILTON VILLA		FACILITY NUMBER:	198600271
ADMINISTRATOR:	ADELA SANTOS		FACILITY TYPE:	735
ADDRESS:	948 SOUTH HAMILTON BLVD.		TELEPHONE:	(909) 620-1933
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	84	CENSUS: 60	DATE:	11/20/2025
		UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Adela Santos, Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not provide the appropriate paperwork to medical personnel
Staff did not seek timely medical care for resident
Resident has unexplained injuries

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro conducted an subsequent unannounced complaint visit at the facility and met with Administrator, Adela Santos and discussed the purpose of the visit.

On 05/30/2025, the initial investigation visit was conducted. The investigation consisted of the following:

The investigation consisted of: Review of resident #1 (R1’s) file and a physical plant tour of the facility. The following documents pertaining to R1 were obtained: Identification and Emergency Information Form, Admission Agreement, Pre-Placement Appraisal, Functional Capability Assessment, Physician’s Progress Notes, House Rules, Appraisal /Needs and Services Plan, Centrally Stored Medication Record/Medication Administration Records (March 2025, April 2025, May 2025), Psychological Assessment, special incident report, and hospital discharge reports.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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 4

Control Number 28-AS-20250530103508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON VILLA	FACILITY NUMBER: 198600271
	VISIT DATE: 11/20/2025

NARRATIVE

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LPA also obtained the staff and client roster. Administrator will send R1’s updated physician’s report to the LPA by fax or email. No health and safety concerns were observed.

During today's visit, LPAs obtained the following documents: staff and client rosters. LPAs interviewed Administrator.

The investigation revealed the following: in regard to the allegation, “Staff did not provide the appropriate paperwork to medical personnel” It is alleged that on 05/13/2025, the facility needed to provide additional documents since the facility only provided a face sheet and the MARs (Medication Administration Record) with C1 to the hospital. LPAs were not able to obtain any other details from the Reporting Party. LPAs interviewed the Administrator that denied the allegation stating that sufficient pertinent forms were sent with C1 to the ER personnel. Administrator stated that the facility protocol is provide face sheet, MAR with client and follow up with the hospital to provide additional information. LPAs observed the following forms that per administrator were sent with the C1 to the ER personnel which include the face sheet and MARs. LPAs reviewed Title 22 Regulations in which there are no written requirement on specific documents to be sent from the facility to the ER. There is not enough sufficient evidence to substantiate.

Allegation: “Staff did not seek timely medical care for resident” It is alleged that on 05/13/2025, C1 complained of pain and C1 was examined at various hospitals and eventually was treated at one of the hospitals. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Douglas. LPAs reviewed IB interviews which revealed the following: During the course of the investigation, it was revealed that on 05/13/2025, C1 complained to staff that C1 was experiencing pain all over C1’s body. C1 was sent to Pomona Valley Hospital by staff that same day (05/13/2025). Per x-rays performed, no acute fractures were discovered. C1 returned to the facility that same day (05/13/2025). However, C1 again complained of pain on 05/16/2025. C1 was sent to Los Angeles Community Hospital by staff that same day (05/16/2025). C1 remained at Los Angeles Community Hospital until 05/24/2025, when C1 was discharged back to the facility. When C1 returned to the facility on 05/24/2025, C1 immediately requested to be sent to Queen of the Valley Hospital late that evening on 05/24/2025 (at approximately 2300 hours). However, when C1 arrived at Queen of the Valley Hospital (at approximately 2330 hours), medical staff at Queen of the Valley Hospital then transferred C1 to Pomona Valley Hospital early morning on 05/25/2025. C1 remained at Pomona Valley Hospital until 06/08/2025, when C1 was discharged and returned to the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20250530103508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON VILLA	FACILITY NUMBER: 198600271
	VISIT DATE: 11/20/2025

NARRATIVE

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Therefore, based on the information obtained during the investigation, the allegation that staff failed to seek timely medical attention for resident, is Unsubstantiated at this time. There is insufficient evidence to substantiate.

Allegation: “Resident has unexplained injuries” It is alleged that on 05/13/2025, C1 has a left black eye, bruises in multiple stages of healing to both arms, abrasions to both knees, and multiple fractures. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Douglas. LPAs reviewed IB interviews which revealed the following: During the course of the investigation, it was revealed that facility client/victim, C1 initially complained of pain all over C1’s body. C1 was transported to Pomona Valley hospital on 05/13/2025, where, per radiology/x-rays of the pelvis and ribs, there was no sign of an acute fracture. C1 returned to the Hamilton Villa facility that same day (05/13/2025). However, C1 was later sent to Queen of the Valley hospital on 05/16/2025, via private ambulance, after complaints of abdominal pain. As a result of x-rays of C1’s left ribs and chest, nondisplaced fractures of the lateral 3rd-8th ribs were discovered. During the investigation, an investigator from CCL (Community Care Licensing) Investigations Branch (IB) interviewed the facility Administrator from Hamilton Villa who stated C1 initially disclosed that someone “hit” C1’s resulting in C1’s having pain. However, C1 could not state who the individual hit C1, what that individual looked like, or where the incident occurred. C1 could only disclose that someone outside of the facility hit C1’s approximately nine months ago. The facility Administrator advised that C1 was “independent” and able to come and go from the facility freely. During the course of the investigation, the IB investigator conducted an interview with C1. C1 informed the IB investigator C1 did not know where or how C1 sustained C1’s injuries. However, during the course of the IB investigator’s interview with C1, C1 then stated C1 was assaulted by individuals who have been “stalking” C1 for years, and they had also assaulted C1 at C1 home in in the past, prior to being admitted to the Hamilton Villa facility. The IB investigator inquired how these individuals were able to gain access to C1’s given the fact C1 lived at the facility. C1 explained to the IB investigator that these individuals were under “FBI protective custody.” Based on all the information obtained during the investigation, including the fact C1 suffers from “Schizophrenia” and has been described by C1’s psychiatric doctor as having a history of “making up” stories of being assaulted, at this time, it is unable to determine how exactly C1 sustained C1’s injuries given the fact C1 indeed presented injuries. Therefore, the allegation of Neglect/Lack of Care and Supervision Resulting in Unexplained Injuries is Unsubstantiated at this time. There is insufficient evidence to substantiate.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20250530103508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON VILLA	FACILITY NUMBER: 198600271
	VISIT DATE: 11/20/2025

NARRATIVE

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Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was held and a copy of this report was provided to the Administrator, Adela Santos.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4