198603307-3-2-2023-28-AS-FFIS-CW9T9H-20231003143157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603307
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:23:43 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230224122909

FACILITY NAME:	CLAREMONT PLACE		FACILITY NUMBER:	198603307
ADMINISTRATOR:	NICOLE VAZQUEZ		FACILITY TYPE:	740
ADDRESS:	120 WEST SAN JOSE AVENUE		TELEPHONE:	(909) 447-5259
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	93	CENSUS: 67	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Meriza De La Cruz- Regional Clinical Specialist		TIME COMPLETED:	03:34 PM

ALLEGATION(S):

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Staff did not respond to facility alarm in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an initial, unannouned visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Regional Clinial Specialist Meriza De La Cruz and explained the purpose for the visit.

LPA Maldonado conducted a tour of the physical plant with assistance from staff Meriza, requested and obtained a copy of the resident and staff roster, incident reports pertaining to residents in the memory care unit for the months of January-February 2023, and the following documents for Residents# 1-5 (R1-R5): Facesheet, Physician's Report, Pre-Admission Appraisal, Current Appraisal, and Needs and Services Plan. LPA also interviewed Staff# 1-5 (S1-S5) and attempted to interview R1, but was unable to due to R1 sleeping at the time of the visit.

The investigation revealed the following:
(Report Continued on LIC9099-C...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20230224122909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/02/2023

NARRATIVE

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Regarding allegation: Staff did not respond to facility alarm in a timely manner.
It is alleged that memory care staff were observed to not respond to the memory care unit alarm system in a timely manner, when it was prompted. At 9:50AM, with assistance of S1, LPA pushed the doorbell for assistance, which is located at the entrance doors of the locked memory care unit on the second floor. After 3 minutes, it was noted that staff did not arrive at the door to open it for LPA and S1. LPA then proceeded to push the delayed egress door to sound the alarm and try to gain entry. After 1 minute of the alarm sounding, a staff came from a room located around the corner, outside of the memory care unit, to input a key code on the side of the door. The alarm turned off and entry was given to LPA and S1. Upon entering the second floor memory care unit, housekeeping staff were observed cleaning the hallway and no residents or other staff were observed on the floor. LPA and S1 met with all memory care staff and residents on the first floor activity room. During interviews conducted, (5) of (5) staff state that the delayed egress alarm on the second floor could not be heard on the first floor, which is why no memory care staff arrived to open the door or turn off the alarm. (3) of (5) staff also stated that due to being short-staffed, all staff and residents are on the first floor for most of the day to allow closer supervision of residents in care. (2) of (5) staff stated it is not due to being short-staffed but rather to allow closer supervision of residents. This allegation is Substantiated.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is Substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with Regional Clinical Specialist Meriza De La Cruz and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230224122909

FACILITY NAME:	CLAREMONT PLACE		FACILITY NUMBER:	198603307
ADMINISTRATOR:	NICOLE VAZQUEZ		FACILITY TYPE:	740
ADDRESS:	120 WEST SAN JOSE AVENUE		TELEPHONE:	(909) 447-5259
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	93	CENSUS: 67	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Meriza De La Cruz- Regional Clinical Specialist		TIME COMPLETED:	03:34 PM

ALLEGATION(S):

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Resident(s) left without supervision while in care.
Staff do not ensure that resident(s) has/have a method to request assistance when needed.
Staff are not ensuring that the needs of bedridden residents are being met.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230224122909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/02/2023

NARRATIVE

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Resident(s) left without supervision while in care.
It is alleged that a bedridden resident in the second floor of the memory unit was observed to be left unsupervised for an unknown period of time. At 10:00AM, LPA inspected the second floor of the memory care unit with S1 and found R1 to be the only resident on the second floor. R1 was observed to be receiving care from S5. S1 stated all residents were brought downstairs to the dining room about 7AM for breakfast, however R1 was not taken down due to their declining health and being weak. After review of R1's Physician's Report and current Appraisal, it was noted that R1 is not a bedridden resident; However, a Physician's Order for R1, dated: 02/06/23 states R1 should be on bed rest and Physician's Order for R1, dated: 02/16/23 states R1 should be up in a wheelchair as tolerated. LPA did not find documentation or orders that indicate R1 requiring 1:1 direct care. During interviews conducted, (5) of (5) staff denied the allegation and stated R1 is checked on every 30 minutes to ensure resident requests and needs are met. This allegation is unsubstantiated.
Regarding allegation: Staff do not ensure that resident(s) has/have a method to request assistance when needed. It is alleged that a bedridden, memory care resident was observed unsupervised on the second floor of the memory care unit, with no apparent way of signaling staff for assistance, if needed. LPA inspected (1) random room on floor# 1 and (2) random rooms on floor# 2. It was discovered that all rooms are equipped with a call light system, which were tested and operational during the time of the visit. During interviews conducted, (5) of (5) staff state that all memory care residents are typically kept together in group activities throughout the day and residents who prefer to be in their rooms are checked on every 30 minutes to an hour for care needs or requests. This allegation is unsubstantiated.
Regarding allegation: Staff are not ensuring that the needs of bedridden residents are being met.
It is alleged that a bedridden resident in the second floor of the memory unit was observed to be left unsupervised for an unknown period of time, with no apparent way of signaling staff for assistance, if needed. After review of R1's Physician's Report and current Appraisal, it was noted that R1 is not a bedridden resident, but does require full assistance with her Activities of Daily Living (ADL's). During the visit, LPA observed S5 providing care to R1. LPA returned to R1's room at about 12:45PM and observed S2 providing care to R1. During interviews conducted, (5) of (5) staff state that there are currently no bedridden residents in the memory care unit and all residents there are frequently checked on- every 30 minutes to 1 hour to ensure all of their care needs/requests are met. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Regional Clinical Specialist Meriza De La Cruz and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230224122909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/10/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator is currently working on hiring more staff and will submit a written plan to LPA via email on how to further address staffing shortages, by the POC due date.
	8 9 10 11 12 13 14	The licensee failed to have adequete staffing in the memory care unit to respond to the facility alarm system in a timely manner, which poses a potential Health, Safety, or Personal Rights Risk to persons in care.	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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