UC Regent DeLaPena

8/14/2019 UC Regent DeLaPena

1/10

-ALIFORNIA FORM 700IR POLITICAL tRACrlCr.:S COMMISSION

(MIDDLE)

S T AT E M E N T O F E C O N O M I C IN T E R ES T S

C O V ER P A GE

ase type or print in ink. A Public DOCUlnent

ME (LAST} (FIRST)

e La Pena William Charles ( 323 ) 728 5500

ILING ADDRESS STREET

ay use business address)

CITY STAT E Z iP CODE OPTIONAL FAX E-M.L,IL ADDRESS

Montebello446 W. Whittier Blvd.

. Office, Agency, or Court

Name of Office, Agency, or Court

University of California

Division, Board, District if applicable:

Board of Regents

Your Position:

Regent

~ If filing for multiple positions, list additional agency(ies)/

position(s): (Attach a separate sheet if necessary)

Agency

Position: -,--- _

2. Jurisdiction of Office (Check at least one box)

!gj State

o County of ----------------o City of _

o Multi-County ----------------

LJ Other ------------------

3. Type of Statement (Check at least one box)

o Assuming Office/Initial Date -----.J-----.J__

I X ! Annual: The period covered is January' 1. 2008.through December 31, 2008.

-or-O The period covered is -----.J-----.J__ , through

December 31. 2008.

LJ Leaving Office Date Left: -----.J-----.J--(Check one)

o The period covered is January 1. 2008. through the

date of leaving office.

-or-

o The f::-eriodcovered is f-----.J , through

CA 90640

4. Schedule Summary

... Total number of pages 10including this cover page: _

~ Check applicable schedules or "No reportable

interests. "

I have disclosed interests on one or more of the

attached schedules

Schedule A-1 0Yes - schedule attached

Investments (Less than 10% Ownership)

Schedule A-2 I R l Yes - schedule attached

Investments (10%or greater Ownersh(o)

Schedule B I R l Yes - schedule attached

Real Property

Schedule C I8 l Yes - schedule attachedIncome, Loans, & Business Positions (Income Other than Giftsand Travel Payments)

Schedule D 0Yes - schedule attached

Income - Gifts

Schedule E nYes - schedule attachedIncome - Gifts - Travel Payments

-or-

o No reportable interests on any schedule

5.Verification

I have used, all reasonable diligence in preparing this

statement I have reviewed this statement and to the best

OhflY knowledge the information contained herein and in anyattached schedules is true and complete.

I certify under penalty of perjury under the laws of the State

of California that the foregoing is true and correct.

Date Signed 3/26f2009/7 {month. day. ye8r}~

/ /.~.~/ // --//>'::"/Signature > / / - ~ CL-"- C/' i>.t;:'-i/ "~ A

- (FHe the originally signed statem"ent "./lith your filing officiaL)

FPPC Form 700 (2008/2009)

FPPC Toil-Free Helpline: 866/ASK-FPPC www-fppc.ca.gov


2/10

I MED-lASER SURGICAL CENTER

SCHEDULE A-2

Investments, Income, and Assets

of Business Entities/Trusts(Ownership Interest is 10% or Greater)

De La Peiia Eye Clinic

Name

2446 W. Whittier Blvd., Montebello, CA 90640

,--- .. " ... '..;,,; .. :c;';:; .,~.

~CAUFORl\I'A F O R M 7 f f J FAIR POUTICAL PRA CT ICEStQr"'llfsiIO~ ~:!. : . . . : : . : ~ _ - : < : . " ' : . : : : ; ) ~ ; ~ \ . , _ , ' . . ~ _ - . . ;_ ::L , -;~ : '";r :--(, ;, . . ; i '_ : . : ' : ~ ' , , : :

I Name

I Wil liam C. De La Per i l

Address

Check one

o Trust, go to 2

Name

2445 W. Whittier Blvd., #100; Montebello, CA 90640Address

Check one

o Trust, go to 2eg Business Entity, complete the box, then go to 2 ! & l Business Entity, complete rhe box, then gGENERAL DESCRIPTION OF BUSINESS ACTIVITY

Ophthalmology Practice',GENERAL .OESCRIPTION OF BUSINESS ACTIVrr;'

IF APPLICABLE. LIST DATE: IF APPLICABLE. LIST DATEFAIR MARKET VALUE

o$2,000 ' $10,0000$10.001 - $100.000

oS100.001 - 51.000.000'~Over 51.000.000

__ 1.._-.108

DISPOSED

FAIR MARKET VALUE

oS2.000, $10.0000$10,001 - $100.000

o$100.001 ' $1.000.000[81 Over S1.000.000

NATURE OF INVESTMENT

~ Sole Proprietorship 0Partnership 0 _O IP

. Qlh~rYOUR BUSINESS POSITION wne!'; resident/PhysiCIan

---"---1~;'COUIRED


!8 l Sole Proprie!Orsllip 0Partnership 0 _YOUR BUSINESS pOSrnON OwnerlPresidentlSurg':>n

o SO - $49905500, S1.000

o $1.001 - $10.000o$10.001 - $100,0001 8 l OVER S100.000

3 : tiS T THE t.J J \t . .'F {)F ["fl.CHRrpORTf~B! ~: 5ri\iGt [ SOURCr OF

INCO~E OF $10.0.~O OR MORE ,'''",,,, ,+~,...'" .~,."'!" ",,0...'',;

o SO, $4990$500, S1.000

o $1,001 ' $10.000oS10,001 ' $100,000I & l OVER $100.000

see attached

~:: liST THE NAME OF EACH HEPORlABLE sir.GtE SOURCE or

INCOM.EOF S1,M!lO.9R..MOi'!E (' '!.!


3/10

SCHEDULE A-2

DE LA PENA EYE CLINIC

ADDITIONAL LEASEHOLD INVESTMENTS

139 S. ALVARADO STREET

LOS ANGELES, CA 92257

FAIR MARKET VALUE $100,001 - 1,000,000

LEASEHOLD FOR 4 YEARS

2715 E. FLORENCE

HUNTINGTON PARK, CA 90255


LEASEHOLD FOR 4 YEARS


4/10

SCHEDULE A-2

INCOME SOURCES OVER $10,000

DE LA PENA EYE CLINIC

BLUE CROSS

BELLA VISTA

CARE FIRST

MEDICARE

MEDICAL

UNIVERSAL CARE

A. DE LA PENA, MEDICAL GROUP, INC

SAN MIGUEL, IPA

ALTAMED

MOLINA HEALTH CARE

ASSOCIATION OF HISP Acl\JICPHYSICIANS

MED-LASER SURGICAL CENTER

MEDICARE

MEDICAL

BLUE CROSS

ST. LUCIA EYE CENTER

A. DE LA PENA, MEDICAL GROUP, INC

SAN MIGUEL, IPA

ALTAMED


5/10

SCHEDULE A"2


of Business EntitieslTrusts(Ownership Interest is 10% or Greater)

.. 1, BUSINESS ErmTY OR TRUST

De La Pena Family Trust dated 11~6/01Name

2446 W. Whittier Blvd., Montebello, CA 90640Address

Check one

l& ! Trust, go to 2 o B'!siness Entity, complete the box, then go to 2

GENERAL DESCRIPTION OF BUSINESS ACTIVITY

FAIR MARKET VALUE

'0 $2,000 - $10.000

0$10,001 - $100,000

0$100,001 - $1,000,000

DOver $1,000,000


o Sole Proprietorship 0Partnership 0 _Other

IF APPLICABLE LIST DATE:

---...J---.I 08ACQUIRED

---1---108DISPOSED

iYOUR BUSINESS POSITION _

0$0 - $499

o $500 - $1,0000$1,001 - $10,000

0$10,001 - $100,000

!8 l OVER $100,000

~ ~ LIST rHErJht-./~[ OF [f..(~H~fPORTAP.LE Slf';G1.f 'SOURCE Of

INCOME OF S10,OOO OR MORE '"',,," " ":,'-". ,,,,,,,,,. C"""",,,~,

CALIFORNIA FORM '1O O FAIR ?QUT1CAL PRf.CTfCES COMMISSIOtt,~';

~,,'d'>!:'

I Name

! William C. De La Pena

De La Pena Family Trust dated 11/26/01Name

2446 W. Whittier Blvd., Montebello, CA 90640Address

Check one

~ T ru st , go to 2 0Business Entity, complete the box, then go to 2

GENERAL DESCRIPTION OF SUSINESS ACTIVITY

IF APPLICABLE UST DATE'FAIR MARK.."'T VALUE

051,000 - $10,000

o$10,001 . $100,0000$100,001. - $1,000,000

DOver S1,000.000

---.J---.108

ACQUIRED---.J---.J

08

DISPOSED

0$0 - $499

0$500 - $1,000

o $1,001 - $10,000

Other

0$10,001 - $100,000

! & l OVER $'100,000

Med-Laser Surgical Center. Goldex Jewelry

,., ? I,:sr TilF ~;M.1For- U.CH R!';JOfH/\BU: SI:'JGIf SOURCE orINCOME OF S1G,OOO OR MORE f"'."h. '.


6/10

SCHEDULE A-2

DE LA PENA FAMIL Y TRUST DATED 11/26/2001

ADDITIONAL INVESTMENTS

2428 W. WHITTIER BLVD.

MONTEBELLO, CA 90640

TENANT: HAMID MALAKOOTI, MD - $10,001-100,000


139 S. ALVARADO STREET

LOS ANGELES, CA 90057

TENANT: DE LA PENA EYE CLINIC - $10,001 -100,000

FAIR MARKET VALUE $100,001-1,000,000

2438 W. WHITTIER BLVD.


. TENANT: DE LA PENA EYE CLINIC

FAIR MARKET VALUE $1,001-10,000

2438 Y z W. WHITTIER BLVD.


TENANT: Fernando Vera $1,000 - $10,000



7/10

SCHEDULE A-2

SECTION 4

DE LA PENA FAMILY TRUST DATED 1112612001

ADDITIONAL INVESTMENTS

PG.2

2715 E. FLORENCE


TENANT: DE LA PENA EYE CLINIC - $10,001-100,000


7145 STAFFORD


TENANT: Uriel Nava $10,001 - $100,000

FAIRMARKETVALUE$100,001-1,000,000

2430 W. WIDTTIERBLVD.


TENANT: NIA

FAIR MARKET VALUE $100,001-1,000,000

2434 W. WHITTIER BLYD.


TENANT: NIA



8/10

SCHEDULE A-2


of Business Entities/Trusts(Ownership Interest is 10% or Greater)

1. BUSINESS ENTITY OR TRUST

De La Pena Family Trust dated 11/26/01

ame2446 W. Whittier Blvd., Montebello, CA 90640ddress

Check one

~ Trust. go [0 2 o Business Entity. complete the box. then go to 2

ENER,i;.L DESCRiPTiON OF BUSiNESS .A.GTIViTY

AIR M,"-.RKET \1.ll,LUE

S2.000 - 510.000

$10.001 - $100.000

5100.001 - $1.000.000

Over S1.000.000

IF A.PPLICABLE. LIST DATE

---.J.---..l 08ACQUIRED

_ _ 1_ _ 108

D!SPOSED

ATURE OF tNvESTrvlENT

~0Soie Proprietorship 0Partnership 0 -,- _ Other

OUR BUSINESS POSITION _

2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE VOUR PRO RATA

SHARE OF THE GROSS INCOME IQTHE ENTrrYfTRUSn

! so - 8499

nS500 - SI :000

o 51.001 - $10.000

! X l $10,001 - S100.000

DOVER $100.000

. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF

INCOME OF S10,GOO OR MORE i.;~."" , .."....' it"*..,,I ," . , ."" .~ , . i

r. Guindi

. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE

BUSINESS ENTITV OR TRUST

heck one box:

o iNVESTMENT f 8 J REAL PROPERTY760 Avenida del Mundo

me of 'Business Entity ill

eet )I.,ddress or p.ssessor's Parcel Number of Real Property

oronado, CA 92118scription of Business Activity Q[

y or Other Precise Location of Rea! Property

IR M."'.RKET VALUE

S2.000 - $10.000

$10,001 - $100.000

n5100.001 - 51.000.000

Over $1,000.000

IF ,A'pPUC,A.BLE. UST DATE:

---.J---.J 08 ---.J__ p8;CQUIRED DISPOSED

TURE OF iNTEREST

Property Ownership/Deed of Trust o Stock o Partnership

nLeasehold C J Other ~ __

Yrs. remaining

Check box if additional schedules reporting investments or real Dropenyare attached

CALIFORNIA FORM 700FAIR POllnCA!. PRACTICES COMMiSSION

Name

William C. De La Pefia

1. BUSINESS ENTITY OR TRUST

Name

Address

Check one

o Trust. g o t o 2 o Business Entity, complete the box, then go to

----------_. ._._------FAiR MJ..RVET 'VAlUE

o S 2.D O I ) . S 10.Q (H : "D$10.001 . SH)O GDOo $iC!0r.JCf $10DL!0CCo O'.l'~r $~.DOG.DOGNATURE. C,F it'J;JESTMENT

n Sote Prop!tt-!t~)fShip n P8;me{~.hlc

,08

.:!:o,(.Cr)JPED

[] ,,-,-

2. IDENTIFY THE GROSS INCOME RECEIVED (lNCWOE YOUR PRO RATA

SHARE OF THE GROSS INCOME 12THE ENTITYITRUSn

050 - $499

05500 - 51.000

051,001 - $10.000

0$10.001 - $100.000

DOVER 5100.000

.. 3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE orINCOME OF S10.000 OR MORE I,>tt.",n " '4'P...~, h... : ',,""' ... -..rf'

Check one box:

o INVESTMENT

~ 4, INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD .Y. THE

BUSINESS ENTITY OR TRUST

o REAL PROPERTY

Name of Business Entity ill

Street Address or Assessor's Parcel Number of Real Property

Description of Business A.ctivity ill

City or~Other Precise Location of Reai Property

FAIR MARf


9/10

SCHEDULE C

Income, Loans, & Business

Positions(Other than Gifts and Travel Payments)

CALIFORNIA FORM 700FAIP. POLmCAl PRACTICES COMMISSION

Name

William C. De La Pena

NAME OF SOURCE OF INCOME


De La Pena Eye Clinic

ADDRESS


BUSINESS ACTIVITY. IF ANY OF SOURCE

Ophthalmology Practice

YOUR BUSINESS POSITION

Owner/President/Physician

GROSS INCOME RECEIVED

o 5500 - 51.000 0 $1.001 - 510.0000510.001 - S100.QOO ~ OVER S100.000

CONSIDERA.TION FOR WHICH INCOME WAS RECEIVED

~ S al ary 0Spouse's Of registered domestic partner's income

o Loan repaymento Sale of

(Property, caT.-boat, etc.)

i j Commission or tJ Rental lncome. list each source of 510,000 or more

UOther{Describe)

. '

Med-Laser Surgical Center

ADDRESS

2445 W. Whittier Blvd., #100; Montebello, CA 90640

BUSINESS ACTIVITY. IF ANY. OF SOURCE

Ambulatory surgical center


Owner/President/Surgeon


o S500 - $1.000 051.001 - S10.0000$10.001 - S100.000 ~ OVER $100.000

CONSIDERATION FOR WHICH INCOME WAS RECEIVED

o Salary n Spouse's or registered domestic partner's incomeo Loan repaymento SaJe of

(Property. car, boac. etc.)

o Commission or 0Rental Income. fist each source of $70.000 or more

Qg Other Owner's draw/Director's fee(Describe]

.. 2. LOANS RECEIVED OR OUTSTANOIToJG DURING THE REPORTING PERIOD

* You are not required to report loans from commercial lending institutions,' or any indebtedness created as partof a retail installment or credit card transaction, made in the lender's regular course of business on terms

available to members of th'e public without regard to your official status. Personal loans and loans receivednot in a lender's regular course of business must be disclosed as follows:

NAME OF LENDER'

Self to De La Pena Eye Clinic

.A.DDRESS


BUSINESS ACTIVITY IF ANY OF LENDER

Administration/Physician

HIGHEST BALA.NCE DURING REPORTiNG PERIOD

[J$500 - $1.000

D $1.001 - S10.000

U$10.001 - $100.000

[gj OVER S100.000

Comments:

INTEREST RATE TERM (MonthsiYears)

_____ % [gj None

SECURITY FOR LOA.N

Q g None 0Personal residence

[] R ear Property Str eet addnE- '. ' ;5

City

oGuarantor --- _

o Other {Describe}

FPPC Form 700 (2008/2009) Sch. C

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov
http://www.fppc.ca.gov/http://www.fppc.ca.gov/


10/10

SCHEDULE C

Income, Loans, & Business

Positions(Other than Gifts and Travel Payments)

CALIFORNIA FORM 7FAIR POLl!lCAl PRACTICES cm'::MI

- -

William C. De La Pen


De La Pena Eye Clinic.ADDRESS

2446 W. Whittier Blvd., Montebello, CA 90640BUSINESS A.CTIVITY. IF ANY. OF SOURCE

Ophthalmology Practice


Book keeping/Managerial


o 5500 - $1.000 0$1001 _ S10.000I 8 J $10.001 - $100.000 0OVER S100.000

CONS!DERATION FOR VVHICH INCOME WAS RECEIVED

oSalary c g ) Spouse's or registered domestic partner's income

o Loan repaymento Sale of -::;:=-:-_--:- _

(Property. car,. boal. etc)

[] Commission or o Rental income. list each source of $10,000 or more

nOther (Describej


YMCA

ADDRESS

12510 E. Hadley, Whittier, CA 90601BUSINESS ACTIVITY, IF ANY. OF SOURCE

Community resourceYOUR BUSINESS POSITiON

Aerobic/Group Exercise Instructor


0 $5 00 - $1 .0 .0 0

o $10,001 - S100,000f Z 1 $1,001 - 510,000

DOVER S100.000

CONSIDERAT!ON FOR WHICH INCOME W,A,S RECEIVED

o Salary 0Spouse's or registered domestic partner's incomeo Loen repaymento Sale of

(Property' car, boal, etc.)

o Commission Or o Rental Income. iist each Source of 510,000 or mo

o Other (Describe)

. . . ' .W lOjM i#N #,',Jji, liiM W illM i,j iM @ iU ii;JigI;'M ### ;1[-1'

* You are not required to report loans from commercial lending institutions, or any indebtedness created as paof a retail installment or credit card transaction, made in the/ender's regular course of business on terms

available to members of the public without regard to your official status. Personal loans and loans receivednot in a lender's regular course of business must be disclosed as follows:

N,A.ME OF LENDER"

Self to Med-Laser Surgical CenterADDRESS

2445 W. Whittier BlVd., #100; Montebello, CA 90640BUSINESS ACTiVITY. IF ANY. OF LENDER

Administration/Surgeon

HIGHEST BALANCE DURING REPORTING PERIOD

o 5500 - 51.000U S1.0Q1 - $10.000

Ll 510.001 - $100.000

I& J OVER S100.000

Comments:

!NTEREST RATE TERM (MonthslYears)

----% I& J None

SECURITY FOR LOAN

I & J None 0Personal residence

E J' Peal Property Sireet address

City

o Guarentcf ___

oOther (Describej

FPPC Form 700 (2008/2009) Sch C

Documents

UC Regent DeLaPena