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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881151
Report Date: 01/15/2025
Date Signed: 01/15/2025 11:54:41 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2025 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250108081519
FACILITY NAME:HACIENDA LIVINGFACILITY NUMBER:
361881151
ADMINISTRATOR:VELAZQUEZ, RAULFACILITY TYPE:
740
ADDRESS:11412 TELEPHONE AVETELEPHONE:
(213) 440-4823
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Raul Velazquez, LicenseeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide responsible party with resident's medication for overnight outing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility conduct complaint investigation regarding the above allegation. LPA Prieto met with licensee Raul Velazquez and discussed the elements of the complaint. Allegation #1, Interview with staff #1 (S1) states that the medication for resident #1 (R1) was provided to R1s responsible party (RP) the day of R1s departure for an outing. S1 adds that RP left behind one medication. Staff #2 (S2) made arrangements with RP, the following calendar day, to retrieve R1's medication. S2 states RP did not comply and medication was not retrieved. S2 states that she volunteered to deliver medication to RP's residence and RP refused.

Licensee Velazquez stated to RP, two calendar days later, that the medication could be retrieved at the facility. RP refused to arrive to the facility to retrieve the medication. Instead law enforcement arrived and retrieved the medication from Licensee Velazquez and given to RP.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 56-AS-20250108081519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
VISIT DATE: 01/15/2025
NARRATIVE
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Interview with RP states that medication was purposefully not included when R1's medication was retrieved from the facility, yet all attempts to deliver or retrieve this medication personally was not successful.

Based on the information obtained there is not enough evidence that staff did not provide responsible party with resident's medication for overnight outing. Therefore, the allegations is deemed UNSUBSTANTIATED at this time. This report was discussed with Licensee Velazquez and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2