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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 04/22/2021
Date Signed: 04/22/2021 04:05:52 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: 72DATE:
04/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administrator, Nicole VasquezTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA) Linda Almaraz and Alberto Lopez conducted a pre licensing tele-visit at Claremont Place as a follow up to initial Pre-Licensing visit conducted on February 10, 2021. 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. During the initial Pre licensing visit applicant had a few corrections needed prior to obtaining a license.

The following items were reviewed and corrected:
Mattress Pads
Trash Can Covers
Replaced drawers in room 160
Drawers for rooms 264 and 108
Night stands for rooms 160 and 264
Exception Letters were obtain for beds in rooms 107 and 206
Non-Skit mat for room 101
CCL “Let Us No" Poster
Personal Rights sign
Emergency Disaster plan posted

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: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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