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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603729
Report Date: 05/07/2026
Date Signed: 05/07/2026 09:12:51 PM

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
04/24/2026 and conducted by Evaluator Gabriela Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260424080523
FACILITY NAME:IVY PARK AT CLAREMONTFACILITY NUMBER:
198603729
ADMINISTRATOR:HERNANDEZ, DAISYFACILITY TYPE:
740
ADDRESS:2053 NORTH TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 57DATE:
05/07/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Daisy Hernandez, AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed.
INVESTIGATION FINDINGS:
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***This report supersedes the report dated 04/30/26 and was updated to correct the date of the medication incident from August 2025 to August 2024. No other changes made to the report findings remain unchanged. ***

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 04/30/2026 to deliver findings related to the above allegation. LPA met with Administrator Daisy Hernandez and explained the purpose of the visit.

The investigation included a review of the client roster, staff roster, R1’s face sheet, R1’s Physician’s Reports, medication documentation, and reimbursement documentation. LPA conducted interviews with two (2) staff members and R1.
(continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
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-20260424080523
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: IVY PARK AT CLAREMONT
FACILITY NUMBER: 198603729
VISIT DATE: 05/07/2026
NARRATIVE
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Allegation: Staff Did Not Distribute Resident’s Medication as Prescribed

It is alleged that facility staff did not ensure that R1’s medication was properly handled and made available as prescribed. During interviews and record review, it was determined that in or around August 2024, there was an incident in which R1’s medication was received by the facility but was subsequently misplaced prior to being provided to R1. Staff acknowledged the incident and reported that corrective action was taken, including reimbursement to R1. During R1’s interview, R1 stated that his medication was delivered to the facility but was not located in his room as expected. R1 reported that he went one day without the medication, requested an overnight delivery, and subsequently received it. R1 further stated that staff provided him with $90 in cash as reimbursement for the misplaced medication. Documentation reviewed included a copy of the funds issued to R1, confirming the reimbursement. However, the Department could not confirm whether a dosage medication was missed as a result of this incident.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260424080523
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: IVY PARK AT CLAREMONT
FACILITY NUMBER: 198603729
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/15/2026
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical ... care shall be developed by each facility. The plan shall encourage routine medical care and provide assistance in obtaining such care, by compliance with the following:
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The facilty will ensure all medications received at the facility are properly logged and immediately provided to the resident or securely stored. A plan will be provided to LPA.
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(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Based on observation, interviews, and record review, facility did not comply with the cited section, as R1’s prescribed medication was misplaced after being received by the facility which poses/posed an immediate health, safety, 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
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