198602882-3-1-2023-28-AS-ALOZ-CPHRBR-20230301115310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:53:26 AM

Document Has Been Signed on 03/01/2023 11:53 AM - 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:	SUNRISE ASSISTED LIVING OF CLAREMONT		FACILITY NUMBER:	198602882
ADMINISTRATOR:	MENSAH, ERIC		FACILITY TYPE:	740
ADDRESS:	2053 N TOWNE AVE		TELEPHONE:	(909) 398-4688
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	81	CENSUS:	DATE:	03/01/2023
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Roger Endert		TIME COMPLETED:	11:57 PM

NARRATIVE

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On 03/01/23, an informal conference/office meeting has been conducted by Licensing Program Manager Fernando Fierros, Licensing Program Analysts (LPA) Alberto Lopez, (LPA) Valeria Maldonado and Supervising investigator Harmin Sandhu along with Administrator Roger Endert and Regional Director of Resident Care Patty Essman. The purpose of the meeting was to discuss the Licensee’s responsibilities in regard to documents subpoenaed by the department and to issue a deficiency for failing to provide records under Title 22 Regulations, Section 87755.

Section 87755 Inspection Authority of the Licensing Agency

The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).

· Licensee will provide requested records that were subpoena and served on 08/03/2021

· Licensee was given form LIC309 Administrative Organization to complete and return to Department.

The following document were requested to be submitted to the Department by 03/06/23.

· Resident/General Liability Incident Report for Resident #1 dated 6/25/20

· Fall Investigation Worksheet for Resident #1, dated 6/26/20

· Resident/General Liability Incident Report for Resident #1, dated 6/26/20

· Resident/General Liability Incident Report for Resident #2, dated 7/04/20

· First “Resident/General Liability Incident Report for Resident #2, dated 9/21/20

Continue on LIC809D

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/01/2023 11:53 AM - 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: SUNRISE ASSISTED LIVING OF CLAREMONT	FACILITY NUMBER: 198602882
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/06/2023 Section Cited	1 2 3 4 5 6 7	87755(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary, for copying. This requirement is not met by evidence of:	1 2 3 4 5 6 7	Licensee will provide all documents to Department and investigation branch by POC date via fax and follow-up with confirmation email.
	8 9 10 11 12 13 14	As of 03/01/2023, the department has not received the requested documentation that was requested by serving subpoena in person on 08/03/2021 and citation will is issued under section 87755 Facility has not provided requested documentation/records that include:1. “Resident/General Liability Incident Report” R1, dated 6/25/20 2. “Fall Investigation Worksheet” for R1, dated 6/26/20 3. “Resident/General Liability Incident Report” R1, dated 6/26/20 4. “Resident/General Liability Incident Report” for R2, dated 7/04/20 5. First “Resident/General Liability Incident Report” R2, dated 9/21/20 6. Second “Resident/General Liability Incident Report” R2, dated 9/21/20	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

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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: SUNRISE ASSISTED LIVING OF CLAREMONT	FACILITY NUMBER: 198602882
	VISIT DATE: 03/01/2023

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· Second “Resident/General Liability Incident Report for Resident #2, dated 9/21/20
· LIC309 Administrative Organization

The Administrator/Licensee have been advised to comply with Title 22 Section 87755(c) Inspection Authority of the Licensing Agency and all other Regulations of Title 22.

Administrator advised to send requested documents to the Monterey Park Adult &Senior Regional Office and the Investigation Branch.

Deficiency cited during today informal conference, refer to LIC809D for details.

Administrator was informed that Civil penalties may be assessed if Licensee does not comply by POC due date.
Administrator will fax to Monterey Park Adult &Senior Regional Office (323) 980-4912 and Investigation Branch (323)-9813876 documents POC date and follow up with email.

Exit interview conducted with Administrator, Roger Endert and Regional Director of Resident Care, Patty Essman and copy of this licensing report and appeal rights has been provided and discussed with Administrator Roger Endert

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

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