198603307-5-19-2023-28-AS-EIRA-CRYQ2G-20230519114706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603307
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:47:12 AM

Document Has Been Signed on 05/19/2023 11:47 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CLAREMONT PLACE		FACILITY NUMBER:	198603307
ADMINISTRATOR:	NICOLE VAZQUEZ		FACILITY TYPE:	740
ADDRESS:	120 WEST SAN JOSE AVENUE		TELEPHONE:	(909) 447-5259
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	93	CENSUS: 66	DATE:	05/19/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	07:45 AM
MET WITH:	Nicole Vasquez		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 05/18/23. LPA met with Nicole Vasquez (Administrator) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant & Environment Safety: Fire extinguishers is located in kitchen and hallways throughout the facility. They have a service date of 02/23/23. Carbon monoxide detectors observed throughout the facility (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Signal system throughout the facility observed (tested and operable). Bathrooms had non-skid surfaces and grab bars. Hot water supply measured at: 109.7* (room 106), 110.3* (room 129), 113.5* (room 156), 114.2* (room 167), 109.0* (room 208), 115.0* (room 214) and 114.9* (rooms 250 and 261). Planned Activities: Calendars and supplies for activities were observed (assisted living and memory care). Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply is stored inside a storage shed. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining room has adequate seating. Posted menu observed. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT PLACE	FACILITY NUMBER: 198603307
	VISIT DATE: 05/19/2023

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Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and//or original containers. LPA reviewed medication for R-1 through R-5. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services.

Exit interview, appeals rights and a copy of this report was provided to Nicole Vasquez.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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