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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 05/20/2025
Date Signed: 05/20/2025 09:35:31 AM

Substantiated


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
10/22/2024 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241022132833
FACILITY NAME:CLAREMONT HACIENDA, THEFACILITY NUMBER:
198603567
ADMINISTRATOR:PEREZ,RICARDO LARAFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:0CENSUS: 1DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ricardo Lara Perez, AdministratorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff restricted resident's visitation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint investigation for the allegation listed above today. LPAs met with Administrator, Ricardo Lara Perez and explained the reason for the visit.

On 11/19/24, the initial investigation visit was conducted. The investigation consisted of the following:
Facility submitted a copy of the resident roster, staff roster, visitation policy, and visitation logs. LPAs interviewed Administrator, Staff #1 (S1) to Staff #4 (S4), and Resident #1 (R1) to Resident #5 (R5). LPAs reviewed and obtained R1’s personnel file: Face sheet, Physician’s Report, Admissions Agreement, Observation Incident Report, Advanced Health Care Directive, Documents from the Superior Court of California, and Appraisal/Needs and Services Plan.

During today's visit, LPA obtained the following documents: resident and staff roster. .

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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 3
Control Number 28-AS-20241022132833
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: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
VISIT DATE: 05/20/2025
NARRATIVE
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Allegation: Staff restricted resident's visitation. It is alleged that the facility staff are restricting visitation between Resident #1 (R1) and one of their family members. It is alleged that the facility staff is supervising the visits, and the family member of R1 is only able to visit for a certain amount of time. LPA interviewed the Administrator and four (4) out of four (4) staff denied the allegation. However, based on staff interviews conducted, the Administrator confirmed that the facility has restricted R1’s visitation rights by limiting R1’s visitor to visit for only 30 minutes at a time, one day a week, and the visits are closely supervised by the Administrator. On 10/22/2024, R1’s family member was allowed to visit R1, however they were only allowed to visit for 30 minutes between 2:00pm-2:30pm and the visit was closely monitored by the Administrator. Facility staff provided a document from the Superior Court of California dated 12/18/2018 that indicated that prior to R1 being visited by this family member, the skilled nursing facility would have to be notified by telephone of the visit at least 24 hours ahead of time and the visit shall be monitored and shall be no longer than 2 hours in duration. However, this document does not discuss any restrictions related to assisted living facilities, it only mentions skilled nursing facilities. The Claremont Hacienda is a Residential Care Facility for The Elderly (RCFE) and not a Skilled Nursing Facility. The court documents that the facility is relying upon indicated only that Skilled Nursing facility visitation is limited. There is no documentation of a current restraining order and there was no other document provided by the facility to justify any limits on R1’s visitation. Five (5) out of five (5) residents interviewed denied the allegation and all stated that they had no concerns on the people that visits them. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.

Based on LPAs observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview held with the Administrator, Ricardo Lara Perez and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241022132833
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: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2025
Section Cited
CCR
87468.1(a)(11)
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(a) Residents in all residential care facilities for the elderly shall have all the following personal rights:
(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.


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Administrator to ensure that all residents have personal rights regarding visitors. Administrator to submit a written statement explaining that they have read and reviewed regulation 87468.1(a)(11) and will ensure to comply with this regulation moving forward.
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This requirement is not met as evidenced by:

Based on staff interviews and record reviews, the facility is violating resident’s personal rights by restricting visitation by limiting visit time and supervising the visits which poses a potential health, safety, and/or personal rights risk to persons in care.
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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: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
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