<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:20:56 PM


Document Has Been Signed on 03/02/2023 04:20 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
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: 64DATE:
03/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Meriza De La Cruz- Regional Clinical SpecialistTIME COMPLETED:
04:30 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
Licensing Program Analyst (LPA) V. Maldonado made an unannouned visit at the facility for the purpose of citing deficiencies for issues observed. LPA Maldonado met with Regional Clinial Specialist Meriza De La Cruz and explained the purpose for the visit.

During the visit, LPA Maldonado 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.

While reviewing documents for R1-R5, LPA noted that (3) of (5) dementia care residents did not have an updated Medical Assessment, but did have a current appraisal. R1 no longer resides at the facility and a current medical assessment is no longer required.

Per California Code of Regulations, Title 22, deficiencies will be cited on LIC9099-D.

An An exit interview was conducted with Regional Clinical Specialist Meriza De La Cruz 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: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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 2


Document Has Been Signed on 03/02/2023 04:20 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
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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited

1
2
3
4
5
6
7
87705 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...done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will have the residents in question reassessed to obtain current medical assessments (physician's report) and will submit to LPA via email by the POC due date.
8
9
10
11
12
13
14
Licensee failed to have current medical assessments for (3) of (5) residents in care, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2