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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:44:06 PM


Document Has Been Signed on 07/27/2023 03:44 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 MANORFACILITY NUMBER:
198601672
ADMINISTRATOR:GREG HIRSTFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:360CENSUS: 278DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robert BartonTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Robert Barton (Executive Director) and discussed the purpose of today’s visit.

This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are (56) residents under Assisted Living. There are no bedridden residents at this time. This facility may retain no more than (10) hospice residents. There are (7) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently 21 residents in the Dementia Unit. The total number of residents at this facility is 278.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are no bedridden residents at this time. This facility may retain no more than (10) hospice residents. There are (7) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently 21 residents in the Dementia Unit.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.

Refer to LIC 809C for the continuation of this report.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 MANOR
FACILITY NUMBER: 198601672
VISIT DATE: 07/27/2023
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The following domains remain pending:
· Staffing
· Personnel Records Training
· Resident Rights- Information
· Resident Rights-Incident Reports
· Physical Plant & Environment Safety
· Planned Activities
· Food Service
· Incidental Medical Services

Exit interview conducted and a copy of this report was provided to Robert Barton.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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