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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881151
Report Date: 10/15/2025
Date Signed: 05/11/2026 01:46:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2025 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250214093747
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: 3DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Raul Velazquez, Administrator/LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee refuse to return resident medication unless rent was paid
INVESTIGATION FINDINGS:
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On 10/15/2025 at 3:30 PM, Licensing Program Analysts (LPAs) Eldin Serrano and Magda Malcore made an unannounced visit to the facility to investigate and deliver the findings on the above allegations. LPAs met with caregiver Vilma Reyes to explain the purpose of the visit. The investigation consisted of interviews with facility staff, witnesses, outside parties, and record reviews.

It is alleged that the licensee refused to return resident medication unless rent was paid. Interviews with facility staff and outside parties revealed that on 9/23/2025, W1 reported that they overheard a phone conversation between resident #1’s (R1) responsible party (RP) and the individual at the facility. W1 reported the phone conversation between responsible party, and facility representative was that the responsible party was told to “bring the check and I will give you the medication.” Interviews further confirmed that R1’s medications were released to the responsible party on January 8, 2025.

********continue on LIC9099C*******

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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-20250214093747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HACIENDA LIVING
FACILITY NUMBER: 361881151
VISIT DATE: 10/15/2025
NARRATIVE
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Based on interviews conducted the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated under the California Code of Regulations Title 22, Division 6 Chapter 8. Deficiency was issued on todays visit recorded on LIC809D dated 5/11/26.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Raul Velazquez.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2