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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601672
Report Date: 09/04/2020
Date Signed: 09/04/2020 05:37:31 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20200831112835
FACILITY NAME:CLAREMONT MANORFACILITY NUMBER:
198601672
ADMINISTRATOR:GREG HIRSTFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:360CENSUS: 205DATE:
09/04/2020
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator, Greg HirstTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents are being double diapered
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Administrator, Greg Hirst.

The investigation consisted of the following: LPA Almaraz interviewed the Administrator, Staff #1-3, and Residents #1-4. LPA also requested and received a staff roster, resident roster, incident reports and Resident #5's file.

The investigation revealed the following: During interviews conducted with staff and residents it revealed only Resident #5 was initially using a diaper and pull-up for support prior to asking the family of Resident #5 to provide underwears. During interviews it revealed it is not a common practice the facility uses and only Resident #5 was using a diaper and a pull-up for support because Resident #5 wiggles a lot and causes the diaper to fall out of place. (Continued on LIC-9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 28-AS-20200831112835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT MANOR
FACILITY NUMBER: 198601672
VISIT DATE: 09/04/2020
NARRATIVE
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Resident #5's file was reviewed. Staff interviewed deny residents are being left in soiled diapers or being doubled diapered. All staff interviewed were consistent in their statements that they change the residents every 2-3 hours and/or more if needed. Residents interviewed did not corroborate the allegation. Therefore, the allegation is unsubstantiated.

A telephonic exit interview was conducted with staff member, Minerva Naranjo and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
LIC9099 (FAS) - (06/04)
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