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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 12/09/2022
Date Signed: 12/19/2022 04:33:25 PM


Document Has Been Signed on 12/19/2022 04:33 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
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: 57DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Administrator Greg HirstTIME COMPLETED:
04:00 PM
NARRATIVE
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LPA Kimberly Ramirez made an unannounced Case Management visit. LPA met with Administrator Greg Hirst and explained the purpose of the visit.

LPA obtained copies of Resident Face Sheet, Facility Self-Assessment of Resident,Preplacement Appraisal Information, Management Medication, Progress Notes, Health and Wellness Review, Resident Appraisal, SIRs. Resident was not available to interview. LPA will return to facility to conduct interviews with staff and resident.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT MANOR
FACILITY NUMBER: 198601672
VISIT DATE: 12/09/2022
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez made an unannounced Case Management visit. LPA met with Administrator Greg Hirst and Director of Residential Services Tanya Madrid and explained the purpose of the visit. LPA was later met by the Director of Health Services Minerva Naranjo.

The visit consisted of interviews with the Director of Health Services, two Staff (S1) and (S2), two (2) residents (R1) and (R2). LPA obtained copies of Physician’s Report for Residential Care Facilities for the Elderly, Resident Face Sheet, Facility Self-Assessment of Resident, Preplacement Appraisal Information, Management Medication, Progress Notes, Health and Wellness Review, Resident Appraisal, Resident Roster, Staff Roster, and SIRs.

LPA will review all documents provided and information provided from today’s visit. LPA may return and request additional information. LPA conducted exit interview.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2