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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 06/10/2023
Date Signed: 06/12/2023 05:59:33 AM


Document Has Been Signed on 06/12/2023 05:59 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 CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:MENSAH, ERICFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 56DATE:
06/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Roger R EndertTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/10/2023 at 8:35 am. LPA was met by Staff 1 (S1) and explained the purpose of the visit. Administrator Roger R Endert arrived to the facility and assisted with tour. Facility is licensed to serve residents over 59 years old. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 9:09 am and was led by LPA. LPA observed the physical plant, residents' medications and records, food supply, and staff records. The facility cares for elderly residents and is approved for 15 hospice residents. There are currently 15 residents on hospice. This facility has a memory care unit.

· Front Yard: Was clean and well maintained. No hazards were observed. No large bodies of water were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. At 9:22 am, LPA observed knives and sharps to be inaccessible to residents in care. LPA observed kitchen staff cleaning kitchen and getting ready to prepare lunch.

· Dining Room/Living room: Dining room was observed to be clean, contain plenty of seating and have sufficient lighting. LPA observed near by thermostat to read 73 degrees F.

· Resident Rooms 1st floor and 2nd floor: LPA selected random rooms to inspect. All contained the required furnishings, linens and were observed to be clean with plenty of closet space. Water temperature in randomly selected rooms were tested and measured to be within the required 105 – 120 degrees F. LPA observed grab bars in bathrooms and showers were treated with non-slip coating.

SEE 809-C for continuation

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023
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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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: 06/10/2023
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· Memory Care Unit: LPA observed delayed egress doors leading into unit entrance. LPA observed facility staff conducting exercise activities with residents in living room area. LPA observed kitchenette to be clean and appliances were observed to be in working condition.

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water were observed.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Roger R Endert with an expiration date of 04/06/24. Last fire drill was conducted on 05/19/23. First Aid kit was observed and inspected. 6 out of 56 resident records were reviewed. 6 staff files were reviewed.

No deficiencies are being cited during visit. Exit interview was conducted with Roger Endert and a copy of this report was provided via email due to printer problems.

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

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC809 (FAS) - (06/04)
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