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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602895
Report Date: 11/04/2020
Date Signed: 11/05/2020 03:47:26 PM

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 PLACEFACILITY NUMBER:
198602895
ADMINISTRATOR:HUNT, LISAFACILITY TYPE:
740
ADDRESS:120 SAN JOSE AVETELEPHONE:
(909) 447-5259
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:93CENSUS: 71DATE:
11/04/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Administrator, Nicole VasquezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted a case management for the above facility to obtain additional information regarding an incident that occurred on 10/26/20 with Resident #1 and Staff #1. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Administrator, Nicole Vasquez.

During the visit LPA interviewed Administrator, Nicole Vasquez, Staff #2-3 and attempted to interview Staff #4-6 but was unsuccessful due to them working nights. LPA also attempted to interview Resident #1 but was unsuccessful due to the resident not being verbal.

Per Administrator, on 10/26/20 at about 8:30AM she was informed by Staff #3 that an incident had occurred between Staff #1 and Resident #1. During the incident Staff #1 and #4 were working the floor but both failed to report the incident. Administrator stated when she was notified about the incident she went to check on Resident #1 and noticed a bruise to the left cheek with 3 finger prints, a large red marking to the right cheek and a swollen top right lip on the resident. As a result, Staff #1 has been suspended pending investigation and Staff #4 was given a final written notice regarding not reporting the incident. The Resident was checked by the Nurse Practitioner from Care More Medical Group and received a facial x-ray that same day.

LPA requested the following documents: Staff and Resident Roster, Resident #1's complete file, any Incident Reports within the last 6 months for the Resident, written statements from Staff #1, #4 and #5, and final written statement given to Staff #4 for not reporting.

No deficiencies cited during todays visit. A telephonic exit interview was conducted with the Administrator and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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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