191500017-12-19-2023-28-AS-KRAZ-CYP2N8-20231219163219

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500017
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:32:58 PM

Document Has Been Signed on 12/19/2023 04:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CLAREMONT SHELTERED CARE CENTER INC		FACILITY NUMBER:	191500017
ADMINISTRATOR:	DEBORAH J. FITCH		FACILITY TYPE:	735
ADDRESS:	650 S INDIANHILL BLVD		TELEPHONE:	(909) 626-3581
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	70	CENSUS: 57	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Direct Support Staff Luz Flores		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required- 1 year visit on 12/19/23. LPA met with Direct Support Personnel (DSP) Luz Flores and explained the purpose of the visit. LPA Ramirez was later met by Administrator Deborah “Debbie” Fitch. The facility is licensed to serve six (6) non-ambulatory and sixty-four (64) ambulatory adults aged 18 – 59 years old. There are three (3) level 1 developmentally disabled clients at the facility receiving services from San Gabriel Valley/Pomona Regional Center. Administrator Certificate 6002383735 expires on 04/07/2025.

The facility is located on a main street and contains six (6) single residential units with two (2) bathrooms in each unit and four (4) client bedrooms in each unit, rear residential unit (San Jose building) one (1) staff office, kitchen, dining area, two (2) TV rooms, food storage room, two (2) detached garages, and two (2) laundry areas. The facility has an enclosed courtyard. LPA Ramirez only conducted physical plant tour today and will return at a later date to complete annual inspection.

Observations:

Kitchen- LPA Ramirez observed facility cook preparing lunch for clients. Water temperature in kitchen sink was measured at 152.2 degrees F. LPA Ramirez observed warning signs near sink indicating water be extremely hot. Sharps and chemicals were observed to locked and inaccessible to clients.

Staff Office- Facility medications are centrally stored and primarily dispensed from the staff office window. LPA Ramirez observed a locked medications cart and a locked medications cabinet in staff office. Staff files and client files are maintained in this location.

Dining Area- LPA Ramirez observed several clients seated in this area. LPA Ramirez observed signs promoting cough etiquette in this area. Fully charged fire extinguishers were observed in this area.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT SHELTERED CARE CENTER INC	FACILITY NUMBER: 191500017
	VISIT DATE: 12/19/2023

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TV Rooms- LPA Ramirez observed two (2) television rooms and observed clients seated in both rooms. LPA Ramirez observed signs promoting hand washing and cough etiquette.

Food storage room- LPA Ramirez observed two (2) refrigerators and two (2) deep freezers in this area. LPA Ramirez observed several large cans of chili beans, boxed pasta noodles, large bottles of spaghetti sauce, pouches of instant mashed potatoes, bags of oatmeal and bags of rice. Facility later had groceries delivered and LPA Ramirez observed sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.

Client Accommodations Units A-F- LPA Ramirez selected random rooms in each unit to inspect. Unit A bathroom#1 water temperature measured at 110.3 degrees F. Bathroom#2 water temperature measured at 111.1 degrees F. Clients’ bedrooms 1-4 all contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. Unit B bathroom#1 water temperature measured at 108.8 degrees F. Bathroom#2 water temperature measured at 116.1 degrees F. LPA Ramirez was not granted entry into client bedrooms 1-4 by clients. Unit C bathroom#1 water temperature measured at 107.3 degrees F. Bathroom#2 water temperature measured at 115.3 degrees F. Clients’ bedrooms 1-4 all contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. Unit D bathroom#1 water temperature measured at 114.3 degrees F. Bathroom#2 water temperature measured at 107.1 degrees F. Clients’ bedrooms 1-4 all contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. Unit E bathroom#1 water temperature measured at 117.3 degrees F. Bathroom#2 water temperature measured at 118.1 degrees F. Clients’ bedrooms 1-4 all contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. Unit F bathroom#1 water temperature measured at 110.9 degrees F. Bathroom#2 water temperature measured at 109.1 degrees F. Clients’ bedrooms 1-4 all contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. San Jose Building- LPA Ramirez observed four (4) additional client bedrooms, kitchenette, and two (2) bathrooms in this building. Kitchenette is not used by clients and there is no refrigerator and dishware in this kitchenette. All client bedrooms contained the required furniture such as bed frames, dressers, lamps, and chairs. Clients’ beds have the required linen. During tour, LPA Ramirez observed housekeeping cleaning bathrooms in units A-D.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT SHELTERED CARE CENTER INC	FACILITY NUMBER: 191500017
	VISIT DATE: 12/19/2023

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Laundry room- LPA Ramirez observed laundry detergent locked in cabinets. LPA Ramirez observed laundry book log nearby. LPA Ramirez observed fully charged fire extinguisher in nearby area.

Courtyard- LPA Ramirez observed courtyard to be free of hazards and no open bodies of water. LPA Ramirez observed staff performing daily maintenance on courtyard.

No deficiencies are being cited. A copy of this report was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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