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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:29:12 PM


Document Has Been Signed on 10/05/2022 03:29 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:GREG HIRSTFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:360CENSUS: 191DATE:
10/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Greg HirstTIME COMPLETED:
03:31 PM
NARRATIVE
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Licensed Program Analysts (LPAs) Alberto Lopez and Kimberly Ramirez made an unannounced Case Management visit. LPAs met with Administrator Greg Hirst and Director of Resident Services Tanya Madrid and discussed the purpose of the visit.

The visit consisted of interviews with Administrator, Director of Residential services, Manager of Memory care, one resident R1 and 1 staff, S1. LPA asked for and obtained facility personnel roster, staff roster, R1 face sheet and R1 Physicians report for residential care facilities for the Elderly, and wrtten statements of 3 staff. S1-S3.
Manager of memory care and Administrator assisted with tour of entire memory care units and LPAs did not observed any health or safety issues while touring memory care unit.

It was reported and confirmed by internal investigation and written statements from staff S1-S3 that R1 was left on the floor for approximately 30-40 minutes. 2/3 staff stated resident was left in wet clothing for approximately 30-40 minutes.

Based upon the information obtained, deficiency cited on LIC 809D. Appeal Rights explained and exit interview conducted with Greg Hirst.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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


Document Has Been Signed on 10/05/2022 03:29 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited

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87468.1(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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According to statements from staff, resident was left on the floor for 30 to 40 minutes in soil clothing which posed a health a safety isuue.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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