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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608258
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:21:51 PM


Document Has Been Signed on 02/13/2024 04:21 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:LEISURE LIVING OF CLAREMONTFACILITY NUMBER:
197608258
ADMINISTRATOR:KATHLEEN GONZALESFACILITY TYPE:
740
ADDRESS:1738 FINECROFT DRIVETELEPHONE:
(626) 622-7296
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Caregiver Semon Orbe TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on 02/13/2024 LPA was met by Caregiver Simon XXXXX and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which five (5) may be non-ambulatory and has a hospice waiver approved for six (6). Bedroom#4 is approved for one (1) bedridden resident. Bedrooms #1,2,3, and 5 are approved for non-ambulatory.

LPA OBSERVATIONS: The facility is a single-story dwelling located on a main street and consists of five (5) resident bedrooms, two (2) full bathrooms, one (1) ½ bathroom, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory device on entry of door to be operational, sliding door and exits.

Front Yard: Well maintained and no hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed weekly menu posted in facility refrigerator. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed a 5-inch monitor on kitchen counter that was displaying live video feed of facility living room, bedroom#2, bedroom#4, and bedroom#5. Kitchen area accessible to residents and visitors.

Dining Room/Living room/: LPA observed six (6) recliners and plenty of lighting in this area. Three (3) out of the five (5) residents were observed seated in this area.

See 809-C for continuation.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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Document Has Been Signed on 02/13/2024 04:21 PM - It Cannot Be Edited

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: LEISURE LIVING OF CLAREMONT
FACILITY NUMBER: 197608258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectants and cleaning solutions were observed to be accessible in bathroom#2, the licensee did not comply with the section cited above in 5 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Staff removed disinfectants and cleaning solutions during visit and secured in another location. Licensee will re-train staff on above regulation and send proof of re-training by 2/27/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/13/2024 04:21 PM - It Cannot Be Edited

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: LEISURE LIVING OF CLAREMONT
FACILITY NUMBER: 197608258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA did not have access to personnel records, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee will certify via email plan to make personnel records accessible to this licensing agency upon demand during normal business hours.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA did not have access to resident records, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee will certify via email plan to make resident records accessible to this licensing agency upon demand.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: LEISURE LIVING OF CLAREMONT
FACILITY NUMBER: 197608258
VISIT DATE: 02/13/2024
NARRATIVE
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Laundry room: LPA Ramirez observed laundry detergent to be inaccessible to five (5) out of five (5) residents in care.

Linen Closet: LPA Ramirez observed plenty of linen, hygiene products and extra toiletry supplies in this area.



Resident Rooms 1-5: LPA Ramirez observed a video camera in four (4) out of the five (5) resident rooms. Resident room#3 is currently unoccupied. LPA Ramirez observed all five (5) resident bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-2 ½: Water temperature in all bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked. Full bathroom showers were observed to contain non-slip mats and raised toilets seats with handles. LPA Ramirez observed signs for proper handwashing procedures. LPA Ramirez observed disinfectants and cleaning solutions to be accessible to five (5) out of five (5) residents in bathroom#2 cabinet. LPA Ramirez will issue deficiency.

Backyard: Well maintained and no hazards were observed.

Garage: Contained emergency water supply, extra food supply and emergency food supply.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Not accessible during visit. LPA Ramirez will issue deficiency.

Resident Records: Not accessible during visit. LPA Ramirez will issue deficiency.

Due to time constraints, LPA Ramirez will return to complete annual inspection and file review. Exit interview conducted. A copy of this report, 809-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/13/2024 04:21 PM - It Cannot Be Edited

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: LEISURE LIVING OF CLAREMONT
FACILITY NUMBER: 197608258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(1)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded safe, healthful and comfortable accoomodations, furnishings and equipment.

This requirement is not met as evidenced by:
Video surveillance was observed in facility common areas, private and shared bedrooms. Facility did not have waiver on file for use of video surveillance.
Deficient Practice Statement
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Based on observation and records review, facility does not have waiver to use video surveillance in private and shared bedrooms, the licensee did not comply with the section cited above in 5 out of 6 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee apply for waiver by 2/27/2024 or discontinue use of cameras in private and shared bedrooms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5