198601672-1-18-2024-28-AS-RORN-CZZSKF-20240131125639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601672
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:40:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/22/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231222125803

FACILITY NAME:	CLAREMONT MANOR		FACILITY NUMBER:	198601672
ADMINISTRATOR:	GREG HIRST		FACILITY TYPE:	740
ADDRESS:	650 W. HARRISON AVE.		TELEPHONE:	(909) 626-1227
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	360	CENSUS: 21	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Wellness director Minerva Naranjo		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff handled resident in a rough manner causing injury
Staff speaks inappropriately to residents
Staff put resident's mattress on the floor

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez made an unannounced subsequent complaint investigation visit on 01/18/2024 to deliver findings and on 12/29/23, LPA Ramirez conducted unannounced subsequent complaint investigation, and on 12/26/2023, unannounced Health and Safety check conducted by LPA Maldonado.

LPA met with Executive Director, Robert Barton, and explained the purpose for the visit. LPA Ramirez requested and obatined copies of Staff# 1-9 (S1-S9): Application for Employment, eight (8) documented interviews conducted facility staff, copies of recent Physician's Report for Residents# 1-3 (R1-R3), Unusual Incident/Injury Report for R1 dated 11/06/23, 12/21/23, Hopsice Physician Order dated 12/11/23 for R1, nursing clinical note for R1 dated 12/17/23, and physical plant tour of memory care. LPA Ramirez interviewed staff and residents.

See 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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-20231222125803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/18/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation(s): Staff handled resident in a rough manner causing injury- It is alleged staff handled resident#1 (R1) in a rough manner causing injury. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. LPA Ramirez reviewed facility staff notes that indicated on 12/10/2023, R1 sustained an injury to R1’s hands and the injury was treated by staff. LPA Ramirez did observe other SIRs indicating R1 having injuries due to unwitnessed falls. LPA Ramirez reviewed nine (9) staff records. LPA Ramirez did observe facility policy on “Adult Abuse” for all staff in staff records. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff speaks inappropriately to residents- It is alleged staff speak inappropriately to residents. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. Facility tour conducted by LPA Ramirez on 12/29/2023, did not reveal staff speaking inappropriately to residents. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff put resident's mattress on the floor- It is alleged staff put R1’s mattress on the floor. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. On 12/29/2023, LPA Ramirez conducted a tour of R1’s room and upon entry observed R1 sleeping in hospital grade bed. LPA Ramirez observed a large blue fall pad on floor near R1’s bed. LPA Ramirez was told by staff that R1 has that fall pad placed on the floor due to R1 being a fall risk. Fall pad is being used to prevent further injury should R1 have another fall. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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