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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603307
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:08:53 PM

Substantiated


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
04/14/2023 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20230414130342
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:
04/24/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Nicole VazquezTIME COMPLETED:
01:22 PM
ALLEGATION(S):
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Facility over charged resident after residents death and did not provide a refund.
INVESTIGATION FINDINGS:
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On 04/24/23 at 009:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Nicole Vazquez (Administrator) and explained the purpose of the visit.

During today’s visit LPA obtained resident/ staff roster, admissions agreement, Resident refund form dated 2/27/2023, Resident refund form date 4/12/2023 and email correspondence showing responsible party payment information. LPA also interviewed administrator Nicole Vazquez.
Report continued 9099c
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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 3
Control Number 28-AS-20230414130342
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: 04/24/2023
NARRATIVE
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Allegation: " Facility over charged resident after residents’ death and did not provide a refund." Based on interviews conducted and document review the findings indicate the facility charged the resident after the resident passed away. Resident (R1) passed away on February 10th, 2023, and the responsible party for R1 removed their belongings on February 22nd, 2023. The facility prorated the rent paid for the month of February and issued a refund to R1's authorized representative on February 27th, 2023, which is within 15 days after the personal property was removed. On Marched 1st 2023, the facility charged R1 rent in the amount of $3064.37. According to Administrator, R1 was on automatic payments and the facility accidentally charged R1 the full amount of rent. The administrator has since worked with their corporate office and refunded R1’s authorized representative on April 12th, 2023. LPA also received proof of payment during the visit.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 06. See LIC 9099D.

Exit interview conducted with Administrator Nicole Vazquez and Appeal Rights provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230414130342
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: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited
HSC
1569.652
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1569.652 (a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.This requirement is not met as evidenced by:
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The administrator provided proof of payment to LPA during the visit. The POC was cleared during the visit.
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Resident (R1) died on 2/10/2023, personal belongings were picked up on 2/22/2023. On 2/27/2023 authorized representative recieved a prorated refund. On 3/1/2023 the facility charged resident (R1) rent in total of $30064.37. The facility issued a refund on 4/12/2023. which poses a potential health, safety, or personal rights risks to persons in care.
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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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3