198603307-5-18-2023-28-AS-RORN-CUKQL9-20230810121534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603307
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:56:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/12/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230512091848

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:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nicole Vazquez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff hit a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Christine Wong conducted an " intial 10 days" complaint visit and ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with the receptionist Amy Vandergrift and explained the reason of the visit. Later on, LPA met with the Executive Director Nicole Vazquez and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed Executeive Director, five staff (S2-S6), ex-employee (S1), six residents (R2-R7) and obtained staff and resident roster, Resident#1 (R1) face sheet, physician report, functional capacity assesment, death report and ex-employee (S1) employee application form, termination notice and the corrective action form and a Special Incident Report dated on 3/8/23.

The investigation revelaed of the following: Allegation "Staff hit a resident while in care." LPA interviewed six residents and stated all staff are nice, kind, supportive and helpful and they never witnessed any staff hit resident while in the facility. (See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230512091848

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/18/2023

NARRATIVE

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LPA interviewed administrator and reported the incident was happened on the night of March 7, 2023. It was reported by R1's daughter on the next morning (March 8, 2023) and the facility also conducted their own investigation and reported to all the required agencies and local law enforcement. S1 was suspended on 3/8/23 and got terminated on 03/10/2023 and R1 was passed on 03/25/23 due to the health deterioration. The witness reported R1 usually required two staff assistance. S1 assisted the witness to change R1 and after they finished changing R1, they realized R1's bedsheet was wet and needed to be changed, but R1 was refused to move and S1 was mad and slapped on R1's face. The witness and S1 attempted to move R1 again and S1 slapped on R1's arm. During the incident, R1 did not observe any injuries.

Based on the interviews conducted with staff and residents and recorded review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D

An exit Interview was conducted with the Executive Director Nicole Vasquez. A copy of the report and Appeal Rights was provided via email.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230512091848

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/01/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rihgts of Residents in All facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature............... ....sleeping, or elimination.	1 2 3 4 5 6 7	The administrator will ensure resident shall have all of the personal right which include to free from punishment, humilation, initmidation, abuse..etc. The administrator will retrain the staff for resident personal right regulation and send the staff training log to LPA by POC due date.
	8 9 10 11 12 13 14	The requirement was not met as evidenced by LPA's interview and record review, S1 slapped R1's face and arm while attempted to change R1's bedding which posed a potential risk to resident in care.	8 9 10 11 12 13 14	(After the incident, the administrator retrained the staff about abuse and mandated reporting on 3/16/23 - POC cleared during the visit)
	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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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