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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603801
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:54:32 PM

Document Has Been Signed on 03/13/2025 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
198603801
ADMINISTRATOR/
DIRECTOR:		PEREZ,RICARDO LARAFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(956) 452-1554
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 68CENSUS: DATE:
03/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Ricardo Lara Perez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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
Licensing Program Analyst (LPA) Daniel Konishi conducted a complaint visit at 8:50am. During the course of the investigation related to Complaint Control Number: 28-AS-20250311170813, Based on record review, Staff #1 was not associated to this facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator, Ricardo Lara Perez.

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

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/13/2025 12:54 PM - It Cannot Be Edited


Created By: Daniel Konishi On 03/13/2025 at 11:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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)
Type A
03/14/2025
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will associate Staff #1 immediately via Guardian and send proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review, Staff #1 (S1) was not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
Page: 2 of 2