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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601672
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:56:50 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
05/03/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210503100322
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: DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Minerva NaranjoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the findings for the above allegation. LPA met with Receptionist Gabby Enriquez and explained the reason of the visit and shortly after, the Director of Health Services ,Minerva Naranjo arrived and assisted with the visit.

The investigation consisted of the following: On 05/04/21, LPA conducted the 10 days initial complaint visit with healthy and safety check and obtained documents for resident#1(R1). On 05/28/21, LPA’s interviewed three staff from memory care unit (S1-S3), three residents (R2-R4) from memory care unit and eleven residents (R5-15) from Assisted Living.

The investigation revealed of the following: Allegation: “Resident sustained fracture while in care.” LPA interviewed staff and reported R1 fell while she’s sleeping and there were no witnesses during the time of the incident. (See LIC 9099C for continuation)


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20210503100322
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: 07/02/2021
NARRATIVE
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Staff reported they followed the protocol and sent R1 to hospital for evaluation and she was back to the facility on the same night because the hospital did not find any injury on R1. A couple days later, R1 felt very painful when staff tried to change her, and they immediately sent her to hospital again. The facility received a call from hospital and reported R1 had a hip fracture. Staff reported that’s the first time that R1 fell and R1 usually needs assistance from staff for transferring in an out from the bed. Staff reported sometimes R1 likes getting out from her bed by herself which R1 was not supposed to do that. In addition, LPA also interviewed residents in the facility from memory care unit and assisted living and all reported staff are able to meet their needs and they take good care of them.

Based on interviews conducted and documents obtained the above allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. Copy of report signed and given to Director of Health Services, Minerva Naranjo
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/03/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20210503100322

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: DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Minerva NaranjoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not make sure resident had their hearing aids.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the finding for the above allegation. LPA met with Receptionist Gabby Enriquez and explained the reason of the visit and shortly after, the Director of Health Services, Minerva Naranjo arrived and assisted with the visit.

The investigation consisted of the following: On 05/04/21, LPA conducted the 10 days initial complaint visit with healthy and safety check and obtained documents for resident#1(R1). On 05/28/21, LPA’s interviewed three staff from memory care unit (S1-S3), three residents (R2-R4) from memory care unit and eleven residents (R5-15) from Assisted Living.

The investigation revealed of the following: Allegation “Staff did not make sure resident had their hearing aids.” LPA interviewed residents and they all reported staff can meet their needs and they take good care of them. (See LIC 9099C for continaution)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210503100322
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: 07/02/2021
NARRATIVE
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LPA interviewed staff and admitted they forgot to send the hearing aids for R1 while staff were rushed sending R1 to the hospital due to emergency. The staff did not attempt to send the hearing aids to R1 or contact the family for picking up while they found out R1’s hearing aids were not sent with resident. The family had to pick up the hearing aids from the facility and delivered them to R1 at the hospital. Besides that, R1 was not able to express well about her health concerns or needs with the hospital staff while she was at the emergency and hospital.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED.. The deficiency is being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights were provided to Director of Health Services, Minerva Naranjo
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210503100322
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations. The requirement was not met as evidenced by :
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The administrator will ensure all the residents shall have the personal right to be accorded safe, healthful, comforable accomodations... The administrator will retrain the staff for personal right and send the copy of training signaute page to LPA by POC due date.
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Based on the interviews conducted, the staf admitted that they were rushed to send R1 to hospital and they forgot to send out the hearing aids with R1 and family had to pick up from the facility and delivered to R1 at the hospital which posed the potential risk to resident.
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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 YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5