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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603307
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:20:21 AM

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 PLACEFACILITY NUMBER:
198603307
ADMINISTRATOR:NICOLE VAZQUEZFACILITY TYPE:
740
ADDRESS:120 WEST SAN JOSE AVENUETELEPHONE:
(909) 447-5259
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:93CENSUS: 73DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Mariano- Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not respond to facility alarm in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Please note: This report will supersede the original report dated: 03/02/23, for the purpose of including additional information regarding interviews conducted with residents during today's visit. The findings regarding the above-mentioned allegation will remain the same: Substantiated.**
Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of conducting resident interviews in regard to the above-mentioned allegation. LPA Maldonado met with Carla Mariano and explained the purpose for the visit.
On 3/02/23, LPA Maldonado conducted an initial complaint visit. The visit consisted of a tour of the physical plant with assistance from staff Meriza De La Cruz, requested and obtained a copy of the resident and staff roster, incident reports pertaining to resident's 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.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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: 08/31/2023
NARRATIVE
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During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and conducted interviews with Residents# 2-6 (R2-R6). LPA was unable to interview Resident# 1 (R1) due to R1 no longer residing at the facility.

The investigation revealed the following:
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. On 3/02/23 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 on 3/02/23, (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. During interviews conducted with resident's during today's visit, (5) of (5) residents could not corroborate the allegation. 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- this allegation did not change since the original report dated: 03/02/23.
Per California Code of Regulations, Title 22, deficiencies were cited on the LIC9099-D, with the original date of: 3/02/23 and citations have been cleared.

An exit interview was conducted with Executive Director, Carla Mariano, and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 PLACEFACILITY NUMBER:
198603307
ADMINISTRATOR:NICOLE VAZQUEZFACILITY TYPE:
740
ADDRESS:120 WEST SAN JOSE AVENUETELEPHONE:
(909) 447-5259
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:93CENSUS: 73DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Mariano- Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
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:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Please note: This report has been amended and will supersede the original report dated: 03/02/23, for the purpose of removing confidential information/resident identifier. However, the findings regarding the above-mentioned allegations will remain the same: Unsubstantiated.**
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 Executive Director, Carla Mariano and explained the purpose for the visit.
On 03/02/23, 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.
(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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: 08/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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On 8/31/23, LPA Maldonado obtained a copy of the resident and staff roster, and conducted interviews with Resident's# 2-6 (R2-R6). LPA was unable to interview Resident#1 (R1) due to R1 no longer residing at the facility.
The investigation revealed the following:
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. On 3/02/23 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 R1's 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 requires 1:1 direct care. During interviews conducted on 3/02/23, (5) of (5) staff denied the allegation and stated R1 is checked on every 30 minutes to ensure resident requests and needs are met. In interviews conducted during today's visit, (5) of (5) residents denied the allegation and stated that staff are always around and nearby. 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. (4) of (5) staff also stated that each resident bedroom is equipped with motion sensors, so anytime motion is detected in their rooms, staff come by to check on them. In interviews conducted during today's visit, (5) of (5) residents stated that staff are always around and check on residents frequently. (3) of (5) residents stated they can call staff via their phones in their rooms for help. 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.
(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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
VISIT DATE: 08/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
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11
12
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32
After review of R1's Physician's Report and current Appraisal, it was noted that R1 is not a bedridden resident. During the visit on 3/02/23, LPA observed S5 providing care to R1. On 3/02/23, 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. In interviews conducted during today's visit, (5) of (5) residents could not corroborate the allegation, as they are unaware of any bedridden residents in the memory care unit. 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 Executive Director, Carla Mariano, and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5