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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600271
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:12:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/08/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211208104413
FACILITY NAME:HAMILTON VILLAFACILITY NUMBER:
198600271
ADMINISTRATOR:ADELA SANTOSFACILITY TYPE:
735
ADDRESS:948 SOUTH HAMILTON BLVD.TELEPHONE:
(909) 620-1933
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:84CENSUS: 52DATE:
04/29/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adela SantosTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The facility has a variety of insects.
The facility is dirty.
The resident was given a medication with no doctors order.
Food service was inadequate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Adela Santos and discussed the purpose of today’s visit. LPA toured facility grounds.

During the initial visit (12/10/22), LPA obtained the following documents: Client Roster and Staff Roster (including staff contact information). LPA obtained a list of Clients that have been discharged/moved out from this facility from September 2021 through December 2021. LPA also interviewed the Facility Administrator. During today's visit, LPA toured facility grounds, interviewed Client #1 through Client #5 (C-1 through C-5) and Staff #1 through Staff #3 (S-1 through S-3).

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
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 3
Control Number 28-AS-20211208104413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 04/29/2022
NARRATIVE
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Allegation: The facility has a variety of insects. During this course of this investigation, LPA interviewed Facility Administrator, S-1, S-2 and S-3. LPA also interviewed C-1 through C-5. LPA also reviewed C-6 file and obtained relevant documentation. Staff interviews revealed that the facility has not had insects (spiders and/or termites). Staff interviews also revealed they have not received any complaints nor concerns from anyone in regards to the facility having insects. Interviewed Clients indicated they have not observed any spiders and/or termites in this facility. Interviewed Clients indicated they have not heard anyone complaining about this facility having insects. Staff and Client interviews do not corroborate this allegation.

Allegation: The facility is dirty. During this course of this investigation, LPA interviewed Facility Administrator, S-1, S-2 and S-3. LPA also interviewed C-1 through C-5. LPA also reviewed C-6 file and obtained relevant documentation. Staff interviews revealed that the facility is maintained cleaned. Staff interviews revealed there has not been any feces on the toilet seats and that staff do not use the same mop used for the floors to clean toilet seats. Per Staff interviews, staff use a designated toilet brush to clean toilets. Additionally, staff interviews revealed that cleaning supplies are replenished on a weekly basis. Client interviews revealed the facility is clean. Interviewed clients indicated they have not observed feces on toilets nor have witnessed any staff cleaning the toilets with mops. Staff and Client interviews do not corroborate this allegation.

Allegation: The resident was given a medication with no doctor’s order. During this course of this investigation, LPA interviewed Facility Administrator, S-1, S-2 and S-3. LPA also interviewed C-1 through C-5. LPA also reviewed C-6 file and obtained relevant documentation. Staff interviews revealed medications are administered at the medication room. Staff that administer medication indicated they only administered medications that have a doctor’s orders. Per staff, medications are noted individually for each Client on a Medication Administration Record (MAR). Additionally, staff revealed that each Client file has a list of the Clients medical physicians contact information noted on the LIC 601 form. Client interviews revealed that clients receive their medication on a consistent basis and that staff do not administer any medication that are not ordered by their doctor. Staff and client interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211208104413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 04/29/2022
NARRATIVE
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Allegation: Food service was inadequate. During this course of this investigation, LPA interviewed Facility Administrator, S-1, S-2 and S-3. LPA also interviewed C-1 through C-5. LPA also reviewed C-6 file and obtained relevant documentation. Staff interview revealed that the facility does not serve burnt or non-edible food. Interviewed staff indicated they have not received any complaints from clients regarding the food service being inadequate. Interviewed Clients indicated that the facility staff do not serve burnt food nor have they heard any clients complaining about the food quality. Staff and client interviews do not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to Adela Santos

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3