<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601672
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:05:57 AM



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
01/07/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220107141402
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: 195DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Administrator, Greg HirstTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staffing levels
COVID guidelines not being followed
Administration of Medication not properly supervised
Resident not receiving proper care
Denied access to visiting resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit. The initial complaint visit was conducted by LPA Nina Galarza on 1/14/22. LPA Vasallo conducted a subsequent complaint visit on 1/26/22.

The investigation consisted of the following: Interviews were conducted with 7 staff members and 2 residents. There are currently 15 residents in memory care. LPA obtained contact information for 5 family members and was able to interview 2 of the families. Resident #1's (R1) file was reviewed. The facility was toured including the Summer House (memory care unit). The incidents allegedly occurred at the Summer House. LPA also randomly chose 5 residents' medications to review.

The investigation revealed the following: Regarding the allegation of low staffing levels, LPA interviewed staff, residents, and residents' families. LPA also reviewed the staff roster. Staff interviewed indicated there is sufficient staff for the amount of residents in memory care.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 3
Control Number 28-AS-20220107141402
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: 02/03/2022
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
26
27
28
29
30
31
32
Residents interviewed indicated there is sufficient staff and described the staff as "great". Families interviewed did not have any concerns regarding staffing levels. At the time of the visit, LPA observed 3 caregivers, an activity person, and an additional staff member administering medication. The previous visit was conducted in the afternoon and LPA observed 3 caregivers. LPA observed food being served, staff passing medication and assisting residents with Activities of Daily Living (ADL's). Based on the information obtained, the allegation is unsubstantiated.

Allegation: COVID guidelines not being followed. Allegedly staff were observed not wearing their masks properly. Staff interviewed denied the allegation. Residents interviewed indicated staff always wear masks. During LPA's visits, staff were always observed wearing the appropriate masks. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Administration of medication not properly supervised. Allegedly there was confusion about R1's medications, however there were no other details provided. R1 is no longer a resident of the facility and therefore the medication cannot be reviewed. LPA reviewed 5 other residents' medications. The medications are documented properly and appeared to be given as prescribed. Staff and residents interviewed did not corroborate the allegation. Families interviewed did not have any concerns regarding the medications. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Resident not receiving proper care. Allegedly R1's briefs were not being changed often enough. This allegedly lead to redness. Staff interviewed denied the allegation and indicated R1 was capable of toileting many days on his/her own. The most recent physician's report dated 9/23/20 indicates R1 is ambulatory and is able to care for own toileting needs. Residents interviewed did not corroborate the allegation. Residents described the staff as "great". Families interviewed did not have any concerns about this allegation. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Denied access to visiting resident. Allegedly a visitor was denied a visit with R1. The facility requires visitors to schedule visits through a website. Allegedly the visitor scheduled the visit and was denied a visit. Staff indicated that at the last minute another visitor cancelled their visit and the visitor for R1 was able to schedule a visit for that same time slot. However, the visiting list was already printing out for the day and staff were unaware that R1's visitor had scheduled the visit and did not allow the visitor in because that time slot was already filled. Due to COVID restrictions, the facility is only allowing 1 visitor at a time. Continued on 9099C.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220107141402
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: 02/03/2022
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
26
27
28
29
30
31
32
Some of the caregivers interviewed remember the incident with R1's visitor and confirmed they did not allow the visitor in because they were not on the visiting list and someone else was scheduled to visit at the same time. Families interviewed indicated they have never been denied a visit. This incident seems to be a scheduling conflict and not a denial of visitation. Based on the information obtained, the allegation is unsubstantiated.

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 held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3