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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 02/10/2021
Date Signed: 02/12/2021 04:49:34 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:
198603307
ADMINISTRATOR:HUNT, LISAFACILITY TYPE:
740
ADDRESS:120 WEST SAN JOSE AVENUETELEPHONE:
(909) 447-5259
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:93CENSUS: 64DATE:
02/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Nicole VasquezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted a pre licensing tele-visit at Claremont Place due to a change in ownership. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this pre-licensing visit was conducted telephonically via Facetime with Administrator, Nicole Vasquez. There are currently 64 residents living in the facility. The fire clearance for Claremont Place was granted on 12/20/2020.

An application was submitted to CCLD on 12/18/2019 for a "change within corporation" for a Residential Care Facility for the Elderly to serve the elderly (ages 60 years and older). The requested capacity is for (83) non- ambulatory; of which, (10) may be bedridden - for a total of (93) residents.

The physical plant was toured and the following was observed.
As part of the Pre-licensing inspection LPA toured the entire facility, inside and out. The facility consists of one, two story, large building with 76 units. The building has (15) Memory Care rooms on the second floor and (15) on the first floor, for a total of (30). There are (9) semi-private rooms on the first floor and (9) on the second floor, for a total of (18). There is a commercial-size kitchen, large Dining Room, Activity Room, Library, Beauty Shop, private dining room, (3) common small living rooms and (2) elevators. The facility has (4) gas fire places which have a glass door and are inaccessible to residents. There is a large court yard with no bodies of water (pool/spa/waterfall) on the premises. The residents suites are spacious and will easily accommodate the resident's furnishings. There is a back yard with a covered courtyard for shade and patio furniture to accommodate the residents leisure time.

*** Continued on LIC 9099-C***
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT PLACE
FACILITY NUMBER: 198603307
VISIT DATE: 02/10/2021
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The inspection consisted all rooms, bathrooms, kitchen, dining areas, activity rooms, medication room, and indoor/outdoor activity areas. The bathrooms are clean and operational with grab bars and non-skid surface/mats in place. The hot water temperature tested at 110.0 degrees Fahrenheit. LPA observed an adequate food supply consisting of at least 2 days of perishables and 7 days of non-perishables. The kitchen appeared to be within Title 22 Regulations. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured room and inaccessible to residents. The memory care unit is equipped with a signal-alarm and delayed-egress system. The smoke alarms are hardwired/interconnected and appear to be operational. Carbon monoxide detectors are battery operated and appear to be operational. Fire Extinguishers are located in the commercial kitchen and throughout the facility.

Component III: Conducted at the Pre-Licensing visit.

LPA observed that the facility does not meet Title 22 Regulations. The following are corrections needed by 2/19/21. LPA will conduct a follow up tele-visit to ensure all corrections are made.
  1. Please ensure all beds have a mattress pad
  2. Trash Can Covers in all bathrooms
  3. Trash Can for rooms 156 and 242
  4. Replace drawers in room 160
  5. Obtain drawers for rooms 264 and 108
  6. Obtain Night stands for rooms 160 and 264
  7. Obtain bed for rooms 107 and 206
  8. Obtain Non-Skit mat for room 101
  9. CCL “Let Us No" Poster to be posted in common areas
  10. Personal Rights sign to be posted in common areas
  11. Emergency Disaster plan to be posted in the Memory Care Unit


Exit interview was conducted telephonically with Administrator Nicole Vasquez. A copy of this report was sent via email for a signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
LIC809 (FAS) - (06/04)
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