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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603801
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:00:13 PM

Substantiated


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
02/06/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250206153352
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:68CENSUS: 30DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Ricardo Lara-PerezTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not accept resident back into care following hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/13/2025 regarding the above allegation,to deliver findings. LPA Ramirez conducted initial complaint investigation on 2/7/25 and a needs further was documented. LPA was greeted by Administrator Ricardo Lara Perez and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview Resident#1-4 (R1 – R4), Interview with R1’s Responsible Party (RP), Interview with R1’s family, Interview with Montclair Hospital Social Worker (SW), Interview with VNA Care Nurse Liaison, copies of resident#1 (R1) Physician’s report dated 09/04/2024, Preplacement Appraisal Information dated 02/6/2025, Claremont Hacienda Observation notes from 01/15/2025 through 02/05/2025, Unusual Incident/Injury Reports from 01/28/2025 through 01/31/2025, Hospice Care Plan, Montclair Hospital Intake Summary, Consult Orders & Discharge Summary, and physical plant tour. SEE 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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-20250206153352
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: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603801
VISIT DATE: 03/13/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff did not accept resident back into care following hospitalization- It is alleged the facility refused to accept R1 back into the facility after R1 had a fall and was ready to be discharged by the hospital back to the facility. Review of R1’s facility record revealed, R1 was admitted into the facility on 12/03/2023. Review of Unusual Incident/Injury Report dated 1/31/2025, revealed R1 was found by staff, lying on their left side, with their head touching the bathroom floor. Staff called 911 and R1 was transported to Montclair Hospital. Facility staff notified R1’s primary care physician and responsible party. Interviews with R1’s family revealed R1 was ready to be discharged on 2/1/25 and family tried multiple times to get R1 back into the facility. R1’s family revealed facility staff refused to accept R1 back into the facility due to R1 having multiple falls and being a fall risk. During records review, LPA Ramirez reviewed R1’s hospital records. R1’s hospital records revealed on 2/1/25, R1’s attending physician documented R1 had multiple falls prior to 2/1/25 and now R1’s assisted living facility (ALF) is unable to accommodate for R1’s care. Two (2) out of the two (2) staff interviewed denied this allegation. Staff interviews revealed staff did not refuse to accept R1 back into the facility, however, staff needed to conduct a reassessment on R1 before accepting them back into the facility. LPA Ramirez reviewed R1’s reassessment conducted by the facility on 2/6/2025. Interviews with Montclair Hospital Social Worker (SW) revealed they began looking for new placement for R1 due to the facility refusing to accept R1 back into the facility after 2/1/25. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. SW revealed R1 did not require skilled nursing care and R1 was placed on hospice care on 2/4/25. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 2/4/2025 and R1’s family has been in contact with VNA trying to find another board and care facility for R1 since R1’s facility was refusing to take R1 back because they were a fall risk. On 2/8/2025, facility staff accepted R1 back into the facility. Although the staff accepted R1 back into the facility on 2/8/2025, staff allowed 6 days to pass before arranging or assisting in arranging R1 with incidental medical care, back into the facility.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. LPA Ramirez will issue a Type A violation based on this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250206153352
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: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/14/2025
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care
(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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incidental medical care. Administrator agreed to draft plan on re-training by 3/14/25. Proof of staff re-training will be sent to LPA Ramirez 3/27/25, via email.
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(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
The licensee did not meet this requirement as evidenced by: facility staff allowed 6 days to pass before arranging or assisting R1's
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3