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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 04/29/2022
Date Signed: 05/03/2022 09:33:19 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/03/2022 09:33 AM - It Cannot Be Edited

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:NICOLE VAZQUEZFACILITY TYPE:
740
ADDRESS:120 WEST SAN JOSE AVENUETELEPHONE:
(909) 447-5259
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:93CENSUS: 67DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Nicole Vazquez, AdministratorTIME COMPLETED:
03:52 PM
NARRATIVE
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On 12/10/21 at 9:15am-Licensing Program Analyst (LPA) Alberto Lopez conducted a Annual infection control visit. LPA's met with Executive Director, Nicole Vazquez and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, Facility has submitted a mitigation plan and the plan has been approved.

LPA's inspected 11 total resident rooms 4 on the first floor and 4 on the second floor and 3 units in the memory care wing. Bathrooms were observed to have non-slip matts, grab bars and water temperature measured between 109.4 to 114 degrees Fahrenheit. The last fire drill was completed on 4/12/23. Administrator certificate expires 4/28/23

The following were observed/inspected:



· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Eleven (11) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms in assisted living were equipped with alcohol-based hand sanitizer and available throughout the facility
· Four (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Not all residents were observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (Please see 809d for details)
Exit interview was conducted with Administrator Nicole Vazquez. A copy of the report was not provided at time of visit due to technical difficulties. 5/02/22 Copy of report 809 and LIC 809D emailed for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 05/03/2022 09:33 AM - 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
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: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Based on observation the facility did not meet this requirement as LPAs and Adminitrator oberseved one borken/not fuctioning properly facet in room 214
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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 YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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