198603307-12-14-2021-28-AS-JHAA-C9KVUA-20211210154426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 12/10/2021
Date Signed: 12/14/2021 08:27:05 AM

Document Has Been Signed on 12/14/2021 08:27 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 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: 75	DATE:	12/10/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nicole Vazquez, Executive Director		TIME COMPLETED:	04:00 PM

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	On 12/10/21 at 9:15am-Licensing Program Analyst (LPA) Hanna and Vasallo conducted a Post Licensing, 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, and reviewed (7) resident and (7) staff files. Facility has submitted a mitigation plan and the plan has been approved. LPA's inspected 5 resident units on the second floor (2 units in the dementia care wing and 3 units in assisted living) and 2 resident units on the first floor ( 1 unit in the dementia care and 1 unit in assisted living)- totalling to 7 units toured. Each apartment inspected, was observed to have smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms were observed to have non-slip matts, grab bars and water temperature between 111 to 115 degrees Fahrenheit. LPA's toured the main kitchen on the first floor and observed all appliances were operating properly. There was a sufficient amount of perishable and non-perishable food, no expired items were observed. The common areas on the first and second floor had been toured: the activity room (1st floor), dining rooms (1st & 2nd floor), library (2nd floor), and poker/billiards space (2nd floor)- were found to be clean and have the required furniture. Carbon monoxide detectors, and fire extinguishers (8 observed, exp 2/2021) were observed throughout the entire facility and found to be up to date. The assisted living and dementia care courtyards has shaded and sitting areas. During the walk through no cameras were observed inside or outside the facility. LPAs reviewed 7 resident files. Files were observed to be complete and had updated emergency contact information. LPAs reviewed 7 staff files. Files were complete including but not limited to first aid certificates, health screenings, proof of training, and proof of fingerprint clearance. LPAs reviewed all residents' medications. Medications are documented properly and given as prescribed. At the time that LPAs entered the facility, LPA's observed sign-in log and self-temperature check. 809C Cont...

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
	VISIT DATE: 12/10/2021

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

Prior to Post Licensing inspection, LPA Hanna received a Hospice waiver increase request from 8 to 14. LPA was informed that facility exceeded the maximum amount listed for hospice residents (8) by 6.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to the Executive Director.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 12/14/2021 08:27 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: 12/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

87633(a)(1)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation/record review/interview, the licensee did not comply with the section cited above Facility has an approved waiver for 8, but has exceeded the allowable number of hospice residents by 6- with a total of 14 hospice residents at the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2021
	Plan of Correction
1 2 3 4	Facility submitted a request for a hospice waiver increase from 8 to 15, and will submit a letter certification indicating that facility will not exceed the allowable number of hospice residents per approved hospice waiver.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3