198603307-2-8-2024-28-AS-KRAZ-D2A328-20240208165132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:51:47 PM

Document Has Been Signed on 02/08/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 70	DATE:	02/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Administrator Carla Mariano		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 02/08/2024. LPA was met by Administrator Carla P Mariano and explained the purpose of the visit. The facility is licensed to serve ninety-three (93) residents over the age of 60, of which ninety-three (93) may be non-ambulatory; ten (10) may be bedridden and has a hospice waiver approved for fifteen (15).

LPA OBSERVATIONS: The facility is a two-story dwelling located in a commercial neighborhood.

Front Yard: Front yard is well maintained, and no hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. Additional food supply is stored inside a storage shed. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. LPA Ramirez observed emergency water and food supply in nearby storage area.

Dining Room/Living room/: Dining room has adequate seating. Posted menu observed.

Activities Rooms: LPA Ramirez several activities rooms on the 1^st and 2nd floor of the facility. LPA Ramirez observed residents performing seated upper body exercises in 1^st floor activity room during tour.

Linen Closet: Contained plenty linens, towels, and hygiene products.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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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Document Has Been Signed on 02/08/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT PLACE	FACILITY NUMBER: 198603307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(b)(2)

Care of Persons with Dementia

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, facility is not addressing safety measure for R8 and R9 while residing in AL with a diagnosis of Dementia, the licensee did not comply with the section cited above in 2 out of 70 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	Licensee will address safety measures for R8 and R9 if they are to remain in AL or move residents to facility memory care.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, R4 did not have annual required medical assessment, the licensee did not comply with the section cited above in 1 out of 70 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	Licensee will retrain staff on this regulation and send proof via email to LPA Ramirez.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT PLACE	FACILITY NUMBER: 198603307
	VISIT DATE: 02/08/2024

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Resident Rooms: LPA Ramirez inspected a total of ten (10) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez toured five (5) resident rooms in memory care unit.

Bathrooms: Water temperature in all bathrooms were measured within 105–120 degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet. LPA Ramirez tested emergency pull cord in bathroom #156 and staff arrived 3 minutes later to assist.

Courtyard: No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: Last documented fire drills were conducted on 12/01/23 and 11/28/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed ten (10) personnel records. Documented proof of required annual initial training and annual training were observed. Administrator's Certificate for Carla P Mariano was observed with an expiration date of 04/04/2024.

Resident Files: Ten (10) resident files were reviewed. Required annual medical assessment for R4 was not observed. R8 and R9’s medical assessment indicated they have a diagnosis that requires staff address certain safety measures such as wandering, aggressive behaviors, and ingestion of toxic substances however, these residents have maintained residence in the facility assisted living apartments. LPA Ramirez will issue two (2) type B deficiencies.

Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance during visit. LPA Ramirez observed updated infection control plan.

Deficiencies are being cited. A copy of this report, 809-D, and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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