198603307-7-13-2021-28-AS-MVAO-C74QKU-20210922121455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603307
Report Date: 07/13/2021
Date Signed: 07/13/2021 05:59:00 PM

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
07/07/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210707120641

FACILITY NAME:	CLAREMONT PLACE		FACILITY NUMBER:	198603307
ADMINISTRATOR:	HUNT, LISA		FACILITY TYPE:	740
ADDRESS:	120 WEST SAN JOSE AVENUE		TELEPHONE:	(909) 447-5259
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	93	CENSUS: 74	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Administrator, Nicole Vasquez		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff did not prevent a resident from wandering while in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Linda Almaraz coducted a complaint visit for the allegation listed above. LPA met with Administrator, Nicole Vasquez and discussed the reason for todays visit.

The investigation consisted of the following: LPA conducted interviews with Administrator and Staff #1-2. LPA also attempted to interview Staff #3 but the staff was on vacation. LPA toured the courtyard and requested Staff and Resident roster and Resident #1's file.

The investigation revealed the following: On 5/21/21, Resident #1 was admitted to the facility. The following day on 5/22/21 at about 7:45AM, Staff #2 let Resident #1 out into the courtyard and went back inside to assistant another resident. About 15-20 minutes later, Staff #2 went outside to check on Resident #1 and could not locate the resident in the courtyard. Records reviewed revealed the residents POA had informed the facility, Resident #1 was an exit seeker. The residents file also revealed resident had wandering behavior and needed special observation due to confusion, forgetfulness and wandering. (Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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

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
07/07/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210707120641

FACILITY NAME:	CLAREMONT PLACE		FACILITY NUMBER:	198603307
ADMINISTRATOR:	HUNT, LISA		FACILITY TYPE:	740
ADDRESS:	120 WEST SAN JOSE AVENUE		TELEPHONE:	(909) 447-5259
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	93	CENSUS: 74	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Administrator, Nicole Vasquez		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident
Facility overcharged services not received

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Linda Almaraz coducted a complaint visit for the allegations listed above. LPA met with Administrator, Nicole Vasquez and discussed the reason for todays visit.

The investigation consisted of the following: LPA conducted interviews with Administrator and Staff #1-2. LPA also attempted to interview Staff #3 but the staff was on vacation. LPA toured the courtyard and requested Staff and Resident roster and Resident #1's file.

The investigation revealed the following: On 5/21/21, Resident #1 moved into the facility and eloped the following day during the morning time. The resident was later found in the City of Chino. The resident was admitted at a hospital in Chino and was later realeased that same day and returned to the facility. Per interviews conducted, the resident was picked up by staff at the facility. (Continued on an LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210707120641

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: 07/13/2021

NARRATIVE

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The facility was in contact with the residents Power of Attorney (POA) and discussed the residents current services. It was determined by the facility the resident needed a 1:1 caregiver and the POA agreed. Records indicate the resident had a 1:1 upon returning to the facility from the hospital. The facility suggested other facilities that would be more suitable for the residents needs since they could not guarantee to the POA resident #1 would not elope from the facility again. The facilities court yard was locked and not opened. It is unknown how the resident eloped from the facility. The POA then looked at the facilities they suggested and voluntarily moved the resident to another facility. The resident was never served an eviction notice and was picked up by the facility staff from the hospital. Regarding the allegation " Staff unlawfully evicted a resident" it is unsubstantiated.

Based on records reviewed there is no extra charges for services not rendered. The resident was charged for the days the resident received care, the days the residents personal belongings were still at the facility. Records also show the charges for the 1:1 caregiver, which the POA approved. Admission agreement between the facility and resident states the agreement may be terminated at any time without a reason with a (30) day notice which was not provided to the facility. Regarding the allegation "Facility overcharged services not received" it 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 cited under California Code of Regulations Title 22. An exit Interview was conducted with Admissions and a hardcopy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210707120641

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: 07/13/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D An exit Interview was conducted with the Administrator and a hardcopy was provided . Appeal Rights was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210707120641

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: 07/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/27/2021 Section Cited CCR 87705(l)(6)	1 2 3 4 5 6 7	87705 (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.	1 2 3 4 5 6 7	The licensee will submit a plan of correction including staff scheduling and supervision of residents who are new admissions. Licensee will also ensure that staff have appropriate training in residents care and supervision. Corrections due to LPA by POC due date of 7/27/21.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Residents #1 eloped from the facility after Staff #2 let the resident out into the courtyard and went back inside for about 15-20 minutes. Resident #1 was found in the city of Chino that afternoon. Resident #1 was taken to a hospital for observation and then later relased.	8 9 10 11 12 13 14
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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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

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