198603801-3-18-2025-28-AS-DSIS-DG2PBR-20250424111046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603801
Report Date: 03/18/2025
Date Signed: 03/18/2025 01:54:12 PM

Unsubstantiated

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
03/14/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250314102426

FACILITY NAME:	CLAREMONT HACIENDA, THE		FACILITY NUMBER:	198603801
ADMINISTRATOR:	PEREZ,RICARDO LARA		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(956) 452-1554
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 27	DATE:	03/18/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	RIcardo Lara Perez, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff mishandled the resident medications.
Staff unlawfully evicted the residents.
Staff did not provide adequate care and supervision to the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Initial 10-Day complaint investigation visit regarding the above allegations. LPA met with Administrator, Ricardo Lara Perez and explained the reason for the visit.

Investigation consisted of: Facility submitted a copy of the resident roster and staff roster. LPA interviewed Administrator, Staff #1 (S1) to Staff #3 (S3), and Resident #1 (R1) to Resident #7 (R7). LPA reviewed medication records and Medication Administration for R1 to Resident #5 (R5). LPA reviewed and obtained documents from S1 and S2 files that include: First Aid Training, ongoing staff, and Medication Management Training. LPA also obtained the eviction letter that was sent to all responsible parties dated 2/21/2025.

[Continued in LIC-C]

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

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-20250314102426

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: 03/18/2025

NARRATIVE

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Investigation revealed the following: Allegation: Staff mishandled the resident medications. It is alleged that the facility has no LVN available to disperse meds to the clients. During today’s visit, LPA interviewed the Administrator and three (3) out of three (3) staff and they all denied the allegation. Seven (7) out of seven (7) residents interviewed denied the allegation. Based on record review and interview, there are no disciplinary documentation for the S1 to S3 files. During the visit, LPA reviewed R1 to R5’s medication and Electronic Medication Administration Record (eMAR) with S2 and all medications are given as prescribed. Based on staff interview, Administrator stated that the former LVN’s last day of employment 3/13/2025. At that time until the present, the facility had trained Med Techs to provide medications for all residents. The new LVN will begin work on 3/19/2025. Based on staff and resident interviews, record review, there was insufficient evidence to corroborate with the allegations.

Allegation: Staff unlawfully evicted the residents. It is alleged that the licensee gave the residents a 90-day notice to move out and the licensee is planning to close the facility. The Administrator, three (3) out of three (3) staff interviewed denied the allegation. Six (6) out of seven (7) residents interviewed denied the allegation. One (1) out of seven (7) residents interviewed stated not knowing about the eviction but indicated that resident’s responsible party most likely would know about the eviction and the facility closing. Based on staff interview, the Administrator was granted approval and sent the letters to all residents’ responsible parties on February 21, 2025, by postal mail regarding the facility closing on May 21,2025. Based on staff interview, the Administrator stated that the residents were informed one to one regarding the closure of the facility and that the facility plans to help provide assistance in finding a placement. Therefore, there was insufficient evidence to corroborate with the allegations.

Allegation: Staff did not provide adequate care and supervision to the residents. It is alleged that the residents are left to help themselves and the current residents need skilled care to provide resources. The Administrator, three (3) out of three (3) staff interviewed denied the allegation. Seven (7) out of seven (7) residents interviewed denied the allegation. Based on staff and record review and interview, there are two (2) caregivers and one (1) med tech on duty per shift. All residents indicated that there are sufficient staff available to help provide care and supervision to meet their needs. LPA observed at the facility activity area that the residents were being closely supervised by the care staff and activity coordinator and that there were no immediate health or safety concerns. Therefore, there was insufficient evidence to corroborate with the allegations.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250314102426

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: 03/18/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED. No deficiencies were cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided to the Administrator, Ricardo Lara Perez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC9099 (FAS) - (06/04)

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