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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603801
Report Date: 05/22/2025
Date Signed: 05/22/2025 01:47:02 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
05/20/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250520115719
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: 0DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Erika Montoya - Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Montoya and explained the purpose of today's visit, shortly after Administrator Ricardo Lara-Perez arrived to assist with visit.

The investigation consisted of the following:

LPA obtained copies of the following documents within Resident #1's (R1) file: Admission Agreement, Physician Report, Court Document, Charting notes from 1/2025-3/2025, Hospital Discharge Paperwork - dated 3/16/25, ALW Assessment - dated 12/23/2, Medication List; and interviewed Staff (S1-S4). Faclity is undergoing closure and there are currently 0 residents admitted in the facility, therefore, there were no resident interviews conducted.

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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-20250520115719
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: 05/22/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff did not safeguard resident's personal items
It is alleged that when R1’s personal items were picked up (as resident was relocated to another facility) most of R1’s clothing was missing. LPA interviewed 4 staff and 4 out of 4 staff stated they did not complete a inventory sheet upon discharge. S2 and S3 stated all items were boxed and sent with resident to new placement upon discharge and no items were left behind. LPA reviewed admission agreement and per admission agreement a personal property inventory is established upon admission and a receipt is to be signed upon discharge. LPA reviewed R1s file and there was no record of the inventory list nor the inventory receipt.

There were no resident interviews done during visit as facility is closing and all residents have been transferred to different facilities, additionally, R1 was not available for interview.

Based on LPAs observations, 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 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250520115719
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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2025
Section Cited
CCR
87218(a)(1)
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87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met as evidence by:
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Licensee/Administrator to review regulation and submit a competed and signed LIC9098 Proof of Correction form to LPA by POC due date. This signed LIC9098 is an agreement stating the regulation has been reviewed, understood, and followed moving foward. tena.herrera@dss.ca.gov
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During interviews 4 staff stated that the personal property inventory was not completed, during file review there was no copy of R1's personal property inventory. Interview with S2 it was expalined that staff were not completing the personal property inventory list.
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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: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3