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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 06/06/2024
Date Signed: 06/06/2024 03:03:57 PM


Document Has Been Signed on 06/06/2024 03:03 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:ROBERT BARTONFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:360CENSUS: 100DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH: Minerva Naranjo (Director of Health Services)TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Minerva Naranjo (Director of Health Services), Tanya Madrid (Director of Resident Services) and Susan DeGange (Q&A Coordinator) 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 eighty-two (82) residents under Assisted Living. There are zero (0) bedridden residents at this time. This facility may retain no more than fifteen (15) hospice residents. There are eleven (11) 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 twenty-two (22) residents in the Summer House Dementia Unit. The total number of residents at this facility is 212.

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

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which five (5) in Summer House Memory Care and five (5) in The Lodge building of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#119. Staff responded 2 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways.

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: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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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: 06/06/2024
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Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets.

Planned Activities: LPA Ramirez observed twelve (12) residents participating in a staff led seated exercise class in the Lodge Lounge room of the facility. LPA Ramirez observed a calendar for June of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drills were conducted on 5/3/24, 3/12,24, and on 02/27/24 during the AM, PM and NOC shifts. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez emergency food supply.



Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order.

Due to time constraints, LPA Ramirez will return at a later time to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Minerva Naranjo (Director of Health Services), Tanya Madrid (Director of Resident Services) and Susan DeGange (Q&A Coordinator). A copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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