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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881151
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:51:49 PM

Unsubstantiated


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:Vilma Reyes, CaregiverTIME 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 and relevant parties.

Based on interviews with facility staff, witnesses, and outside parties, there is no evidence to support the allegation that the licensee withheld resident #1 (R1’s) medication pending rent payment. According to interviews, R1’s responsible party arrived at the facility on January 6, 2025, to take R1 on a vacation and collected R1’s personal belongings, including medications. All medications were retrieved at that time except for one bottle, which was subsequently provided to R1’s responsible party on January 8, 2025. The licensee denied the allegation, and no witnesses corroborated claims of R1’s medication being withheld due to unpaid rent.

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

Unsubstantiated
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 the interviews conducted, the allegation mentioned above is Unsubstantiated. A finding that the complaint is Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to the caregiver Vilma Reyes.
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