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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600271
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:59:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/13/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220613104856
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: 65DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Adela Santos TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff sexually abused resident
Resident sustained multiple injuries while in care
Resident is over medicated
Staff do not assist residents with incontinence needs
Staff have not observed resident's change in condition
Staff did not report incident to resident's representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Administrator Adela Santos who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 6/14/2022, LPA Mora requested a copy of staff and client rosters and conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On today's date, LPA Wong interviewed the administrator, seven clients (C1-C7), three staff (S1-S3) in the facility and one staff (S4) via phone and obtained C1's face sheet, preplacement appraisal information, admission agreement, needs and servicer plan dated on 1/16/23, physician report dated on 06/02/21, medical progress notes dated on 01/11/22, 02/08/22 and 03/07/22, dental appointment dated on 12/8/21, unusual incident/injury report dated on 06/09/22 and 06/10/22. (See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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 6
Control Number 28-AS-20220613104856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 02/21/2023
NARRATIVE
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The investigation revealed of the following: Allegation#1 "Staff sexually abused resident " The complaint was accepted by the CCL IB investigation Unit as an assignment and assigned to IB Investigator Douglas Reel. IB Investigator Reel conducted an interview with C1 and C1's statement were inconsistent and denied staff or anyone else in the facility sexually assaulted or physically harmed C1. C1 also could not provide any information or details regarding the alleged assaults. LPA Wong also interviewed clients and all denied the allegation and they never heard or witnessed any staff raped clients in the facility. LPA also interviewed staff and all denied the allegation and reported there's never happened in the facility.

In regard to allegation#2 "Resident sustained multiple injuries while in care" LPA interviewed clients and all denied the allegation and reported staff are on top of their medical and staff take good care of them. LPA interviewed staff and all denied the allegation and reported that they had never seen C1 sustained any bruises or injuries on her shoulders or hands. Staff reported that if they saw something, they would send clients to hospital immediately or take them to see doctor right away.

In regard to allegation #3 "Resident is over medicated" LPA interviewed seven clients and six out of seven clients denied the allegation and stated they did not think staff would over medicate them. Staff are always on top of their medication. LPA interviewed staff and all denied the allegation and reported clients' medication are always prescribed by clients' doctors and psychiatrist. Staff always administered clients' medication according the time and dosage. LPA also reviewed clients' medication and MARs and they are all accurate and updated.

In regard to allegation#4 "Staff do not assist residents with incontinence needs" LPA interviewed clients and all denied the allegation and reported they are all independent with their personal hygiene and daily living skills. They are all capable to complete their own shower and toileting. They do not need any assistance with showering or toileting. LPA interviewed staff and they all denied the allegation and reported all clients are independent with their shower and toileting. Staff stated that they never seen C1 had feces or urine on her body or clothes. Staff reported C1 took her shower everyday and C1 always put on clean clothes. C1 would never have any smell on her body.
(See LIC 9099C for continuation)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220613104856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 02/21/2023
NARRATIVE
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In regard to allegation#5 "Staff have not observed resident's change in condition" LPA interviewed clients and reported they usually would tell staff if they are not feeling well or sick. Staff always stay on top of their health as well. LPA interviewed staff and reported most of the clients are able to tell the staff that they are not feeling well. Staff also stated if clients missed the medication and staff would go to their room and ensure they are well and safe. Staff would also be able to observe clients change in condition by monitoring them or by their behaviors.

In regard to allegation#6 "Staff did not report incident to resident's representative" LPA interviewed clients and reported staff would notify their family or authorized representative if something happened to them. LPA interviewed administrator and administrator reported that C1 is not conserved and C1 is self responsible. C1's family was just C1's emergency contact person and facility is not mandated to report. Facility did follow the protocol by reported to the local enforcement while C1 was eloped.

Based on the interviews conducted with clients and staff and recorded review, 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 #1, #2, #3, #4, #5 and #6 are found to be UNSUBSTANTIATED.

Exit Interview conducted and a copy of the report was provided to Administrator Adela Santos
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/13/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220613104856

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: 65DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Adela Santos TIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff did not seek dental attention for resident in care
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Administrator Adela Santos who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 6/14/2022, LPA Mora requested a copy of staff and client rosters and conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On today's date, LPA Wong interviewed the administrator, seven clients (C1-C7), three staff (S1-S3) in the facility and one staff (S4) via phone and obtained C1's face sheet, preplacement appraisal information, admission agreement, needs and servicer plan dated on 1/16/23, physician report dated on 06/02/21, medical progress notes dated on 01/11/22, 02/08/22 and 03/07/22, dental appointment dated on 12/8/21, unusual incident/injury report dated on 06/09/22 and 06/10/22. (See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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 6
Control Number 28-AS-20220613104856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 02/21/2023
NARRATIVE
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The investigation revealed of the following: Allegation#1 "Staff did not seek dental attention for resident in care," LPA interviewed seven clients and six out of seven clients and reported that they haven't seen dentist for a long time and they all wanted to see a dentist and no appointment was set up by the facility. LPA reviewed C1's dental record and her last seen was on 12/8/21 and C1 was supposed to have a follow up dental appointment in two weeks but no appointment was set up since the last dental appointment on 12/8/21, C1 did not have any recent dental appointment. C1 reported teeth is hurting and no dental appointment was set up yet.

Based on LPA’s observation, interviews and records review, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED.

Deficiency was observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC9099D.

Exit interview held, copy of report and Appeal Rights provided to the administrator Adela Santos.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220613104856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON VILLA
FACILITY NUMBER: 198600271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited
CCR
80075(a)
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80075 Health Related Services (a)The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The administrator will ensure client would receive needed medical and dental services. The administrator will assist client and arrange the dental appointment for them. And send the information to LPA by POC due date.
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The requirement was not met as evidenced by : LPA's interviews, LPA interviewed 7 clients and 6/7 clients reported they haven't seen dentist for a long time and they never had any dental appointment got set up by faciltiy which posed a potential risk for clients in care.
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CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6