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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603801
Report Date: 11/05/2025
Date Signed: 11/05/2025 02:07:57 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
03/11/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250311170813
FACILITY NAME:CLAREMONT HACIENDA, THEFACILITY NUMBER:
198603801
ADMINISTRATOR:PEREZ,RICARDO LARAFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(956) 452-1554
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:0CENSUS: 0DATE:
11/05/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff hit resident causing injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi mailed a copy of this report to the former licensee's last known mailing address via USPS certified mail to communicate the findings related to the above-mentioned allegations. The facility has been closed since 05/23/2025.

On 03/13/2025, the initial investigation visit was conducted. The investigation consisted of the following:
Investigation consisted of the following:

LPA requested a copy of staff and client rosters. LPA conducted a tour of facility and common areas with the Administrator. LPA also requested copies from Resident #1 (R1’s) file such as: Identification and Emergency Information, Admission Agreement, Admission Record, Physician's Report, Special Incident Reports. The Administrator will send Appraisal Needs and Services Plan and Pre-Placement Appraisal to the LPA.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
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-20250311170813
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: 198603801
VISIT DATE: 11/05/2025
NARRATIVE
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LPA also requested copies of the Staff #1 (S1) and Staff #2 (S2) file such as: Code of Conduct, Receipt of Acknowledgement of Employee Handbook, Criminal Background Clearance, Employee Warning Document, BLS training, On-the-Job Orientation Training, and Position Description. LPA interviewed R1 and the Administrator during the visit.

On 05/15/2025, LPA interviewed Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), and the Administrator over the phone.

On 06/20/2025, LPA interviewed R1’s family member and obtained a photograph of R1’s injuries taken after the incident.

The investigation revealed the following: in regards to the allegation: “Staff hit resident causing injury.” It is alleged that on 3/10/2025, at 5am, R1 was struck in the face by S1 resulting in a black eye when staff were attempting to change R1. Shortly after the incident, Claremont Police were called, and they arrived at the facility on 3/10/2025. LPA interviewed R1 and R1 indicated that they were “picking” at their eye because it was itchy and could not recall being hit by S1 or any other staff. LPA interviewed S1 and S1 denied the allegations stating that S1 did not hit or strike R1 in the face and S1 was unsure of how R1 had obtained the black right eye. LPA interviewed the Administrator and the Administrator stated that S1 was initially suspended pending an investigation, however at the conclusion of their internal investigation S1 was terminated because management felt reasonable suspicions that S1 had in fact struck R1 in the face. LPA interviewed S2 and S2 corroborated with the allegation stating that S2 witnessed S1 striking R1 on the face during the 03/10/2025 incident. S2 indicated that they were present during the interaction and S1 aggressively slapped R1 in the face when R1 was being combative with staff as they were attempting to change R1. LPA interview S3 and although S3 did not directly witness the incident, S3 corroborated the allegation by confirming that R1 had an injury near their right eye the day of the alleged incident. LPA obtained a copy of the police report from the Claremont Police Department that indicated that law enforcement responded to the facility to investigate the incident and the police officer observed redness and bruising around R1’s right eye. LPA also reviewed picture that was provided regarding R1’s injury and the picture shows redness around R1’s eye area. Based on staff and resident interviews, record review, there was sufficient evidence to corroborate with the allegations.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20250311170813
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: 198603801
VISIT DATE: 11/05/2025
NARRATIVE
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Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.

An immediate $ 500.00 Civil Penalty is being issued as a result of staff causing injury to resident in care.

Copy of this report and appeal rights will be mailed to the licensee’s last known mailing address via USPS certified mail as the facility closed effective 05/23/2025.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20250311170813
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: 198603801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2025
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidenced by:
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Administrator/Licensee to ensure that each resident has personal rights. Administrator/Licensee is to ensure that all residents are free from corporal or unusual punishment at all times.
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Based on interviews and record review, obtained, Administrator failed to ensure the safety of Resident #1 (R1) from suffered a eye injury from Staff #1 (S1) hitting R1 while in care. This poses a immediate health, safety or personal rights risk to residents 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: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4