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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:33:08 PM


Document Has Been Signed on 07/28/2022 03:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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: 196DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Administrator, Greg HirstTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual visit to the facility. LPA met with Administrator, Greg Hirst and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, residents' medications and records, food supply, and staff records. The facility cares for elderly residents and is approved for 10 hospice residents. There are currently 7 residents on hospice.

Administrator and maintenance staff assisted with the tour of the facility. The facility is a large campus that includes independent living, assisted living, memory care and skilled nursing. The assisted living and memory care buildings were toured. The Lodge is a two story building for assisted living residents. The building consist of resident bedrooms, kitchenette, dining room, activity room, and beauty salon. The furniture in the dining room and activity room is adequate. The hallways and stairways are clear and free of any obstructions. The second-floor stairways have the required evacuation chairs. Resident rooms were randomly chosen for inspection on the first and second floor. 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 106.3 - 114.2 degrees, which is within the required 105 - 120 degrees. Elevators were operating at the time of the visit. The Summer House is a separate building for memory care residents. The memory care unit requires a code to enter. The building was toured and was observed to contain all required items.

The main kitchen was toured. 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, carbon monoxide detectors and fire extinguishers located throughout each building. The grounds are properly maintained and there were no hazards observed. The pool has a gate around the entire perimeter and has self-latching doors. Continued on 809C.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 07/28/2022
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There is a screening station at the entrance of the facility to screen visitors. Staff document temperatures daily and require visitors to sign in. Facility currently has at least a 60-day supply of PPEs.

Five resident records were reviewed to confirm emergency contacts are updated. Staff also document resident temperatures and any COVID-19 symptoms daily. Five staff records were reviewed to confirm health screenings, training, fingerprint clearances, and vaccination status. All records were complete. LPA reviewed three residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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