<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603801
Report Date: 05/22/2025
Date Signed: 05/22/2025 01:47:54 PM

Unsubstantiated


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):
1
2
3
4
5
6
7
8
9
Staff did not address a change in resident's health condition
Staff did not address resident's scabies infection
Staff chemically restrained resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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)
Unsubstantiated
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 2
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
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
The investigation revealed the following:
Allegation: Staff did not address a change in resident's health condition
It is alleged that staff did not address R1’s health because the resident’s conservator refused treatment. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that they do not refuse residents at the facility treatment when needed, additionally staff stated that R1’s conservator has never instructed staff to refuse treatment for R1. LPA reviewed Assisted Living Waiver assessment for R1 dated 12/2024 and there were no notations or observations made stating that R1 had a change of condition, these assessments are done every 6 months and this assessment was the most recent. LPA reviewed hospital discharge paperwork dated 3/16/24 and resident was sent back to facility with no new medications or orders. LPA reviewed R1’s charting notes and there weren’t any notes indicating resident had a change of condition (notes of hospitalization was listed on charting notes).

Allegation: Staff did not address resident's scabies infection


It is alleged that staff did not seek treatment for R1 as the resident’s conservator refused treatment. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, each stated that there had not been any residents with scabies and R1 did not have any questionable skin marks to assume R1 had scabies. LPA reviewed R1’s file and there was nothing documented within file that stated resident had scabies.

Allegation: Staff chemically restrained resident


It is alleged that staff were over-medicating R1 leaving resident drowsy and sleepy. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that R1 had very little medications prescribed and MedTech’s administered medication to R1 per the doctors order. S1 and S2 stated that medication that R1 would take did have side effects that would make the resident sleepy therefore these medications were given to resident at bedtime. LPA reviewed R1’s medication list and observed 2 medications that were prescribed by physicians, side effects listed did include drowsiness.

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 statements and interviews conducted, review of resident file and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was 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 2