198601672-10-28-2021-28-AS-CWOG-C87UA2-20211027152401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 10/27/2021
Date Signed: 10/28/2021 08:04:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 213	DATE:	10/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Minerva Naranjo		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Christine Wong, Cynthia Chan and Alma Gonzalez conducted an annual required visit. LPA's met with Director of Residential Services, Minerva Naranjo and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and approved on 04/10/21. The facility is located in a large campus that includes independent living, assisted living, memory care and skilled nursing. The assisted living and memory care buildings were toured. The assisted living building has 2 floors. The first floor consist of resident bedrooms, kitchen, dining room and activity room. The furniture in the dining room was adequate and the kitchen was clean. The appliances were working properly. The refrigerators and freezers are set at appropriate temperatures. There was sufficient perishable and non-perishable food and the food is stored properly. There are smoke detectors and fire extinguishers located throughout the building and they are operational. The hallways and stairways are clear and free of any obstructions. LPA inspected Room#102, #104, #107, #116, #209, #214. The rooms are properly furnished with bedframes, dressers, lamps and chairs. The beds have adequate linen. The bathrooms have the required grab bars near the toilet and in the shower. The hot water was tested and was between 115.7 and 118.9 degrees, which is within the required 105 - 120 degrees. The memory care unit was also toured. The memory care unit is a cottage that is separate from the assisted living building. Memory care unit has three different houses with separate key pad entrance. It consists of dining area, kitchen and laundry room. LPA inspected Room#1, #5, #7, #10, #12, 13. Bedrooms have the required furniture and bathrooms have the required grab bars. The hot water was tested and it was between 109 and 116 degrees F, which required 105-120 degrees F.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT MANOR	FACILITY NUMBER: 198601672
	VISIT DATE: 10/27/2021

NARRATIVE

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LPA's reviewed ten (10) resident files to confirm emergency contact is updated. LPA's also reviewed staff files to confirm health screenings and fingerprint clearances. LPA's reviewed 10 residents' medications included four (4) residents in memory care unit and six (6) residents in assisted living. Seven (7) Residents have no PRN medication located in the facility.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected all day long, restrooms have sufficient soap, paper towels, and signs, facility has an isolation room and a cart with PPE supplies, and PPE supplies are sufficient for more than 30 days.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on 809D. Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465(c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviewed, LPAs observed seven (7) residents' PRN medications are not located in the facility which posed the immediate risk to the residents in care
	POC Due Date: 10/28/2021
	Plan of Correction
1 2 3 4	The administrator will review the residents PRN medication and see if it's needed to be discontinued or re-ordered the medication if needed and please send the picture of the re-ordered medication and discontinuation notice to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3