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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603425
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:23:36 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
10/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221010131204
FACILITY NAME:CLAREMONT HACIENDA, THEFACILITY NUMBER:
198603425
ADMINISTRATOR:PAOLI, FREDERICKFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:0CENSUS: 49DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Denise Downey, Acting AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet the needs of the residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegations and delivered findings. The purpose of the visit was discussed with Acting Administrator Denise Downey of new licensee Ally Senior Living LLC.

The investigation consisted of: On 10/13/22, LPAs Galarza & Kimberly Ramirez conducted a physical plant tour of the facility common areas/wings, outdoor grounds, random rooms, and kitchen. The two (2) day perishable and seven (7) day food supply were inspected, and dietary procedures were reviewed. Staff (S1- S14), family members (F1 & F2), and residents (R1- R8) were interviewed. The following documents were obtained: LIC 500 Personnel Report, resident roster, monthly food menu, weekly food menu, special diet/special food request list, kitchen staffing schedule, resident council minutes (9/1/22) and hospice list. On 10/19/22, 2 additional staff were interviewed telephonically. During today's visit, a physical plant tour of the facility was conducted with focus on meal service and review of staffing schedules and file review. LPA interviewed Acting Administrator and obtained R9’s file documents.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 5
Control Number 28-AS-20221010131204
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 HACIENDA, THE
FACILITY NUMBER: 198603425
VISIT DATE: 03/08/2024
NARRATIVE
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Allegation: "Facility does not have sufficient staff to meet the needs of the residents in care." It is alleged that the facility is understaffed in the evening and/or night shifts with only 2 caregivers and 1 medication technician, resulting in the inability to meet the incontinent care needs of residents in a timely manner. Based on information obtained, there are at least 6-7 residents whose aggressive behaviors or body size require two (2) staff assist during diaper change and bathing assistance, and while staff are changing the residents the other resident's needs are not being met. According to interviews, on days when there are shift staffing shortages i.e. 1 or 2 caregiver staff in the PM or night shifts not all of the Memory Care residents are assisted in a timely manner. The facility has contracted registry staff personnel, but when there are last minute staff absences registry staff are often not available to cover the shift. All staff interviewed stated they try their best to meet the needs of the residents. Of main concern is that when there are caregiver staffing shortages there have been insufficient number of staff on shift to meet the needs of the residents. Staff acknowledged staffing issues, especially on Friday and Saturday NOC shift hours. Family members interviewed are satisfied with resident care, but stated there have been times in which there is insufficient staff to meet the needs of the Dementia residents. Staff interviews revealed that Dementia resident (R9) eloped twice from the facility, the 1st time on 8/13/2022, in which the resident broke a window and got out and was found 7 houses away. The 2nd elopement incident occurred in September 2022, after their return from a hospitalization. NOTE: the elopement incidents were not reported/faxed to CCL. Per Plan of Operation staffing plan "The licensee shall ensure that there is an adequate number of Caregivers to support each resident's physical, social, emotional, and safety and health needs as identified in his/her current appraisal. Staffing shall be based upon the needs of our residents." During today's visit, staff provided a copy of only 1 elopement incident pertaining to resident (R9). Today's staffing schedule shows sufficient staffing. However, there is sufficient evidence to corroborate the allegation.


Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

An exit interview was conducted, a copy of this report and appeal rights were provided to Acting Administrator Denise Downey.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20221010131204
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 HACIENDA, THE
FACILITY NUMBER: 198603425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87411(a)
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Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by evidence of:
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Administration staff agrees to submit a written plan that states how the deficiency was corrected, and proof of staff training.
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Based on record review and interviews conducted between Jan. 2022 – Sep. 2022 the facility was experiencing staffing shortages. Resident (R9) eloped twice (Aug. 2022 & Sep. 2022) because staff were not checking the resident as required due to staff shortages. This posed a potential health and safety risk to residents 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) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221010131204

FACILITY NAME:CLAREMONT HACIENDA, THEFACILITY NUMBER:
198603425
ADMINISTRATOR:PAOLI, FREDERICKFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:0CENSUS: 49DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Denise Downey, Acting AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility fails to provide residents with a nutritious diet.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegations and delivered findings. The purpose of the visit was discussed with Acting Administrator Denise Downey of new licensee Ally Senior Living LLC.

The investigation consisted of: On 10/13/22, LPAs Galarza & Kimberly Ramirez conducted a physical plant tour of the facility common areas/wings, outdoor grounds, random rooms, and kitchen. The two (2) day perishable and seven (7) day food supply were inspected, and dietary procedures were reviewed. Staff (S1- S14), family members (F1 & F2), and residents (R1- R8) were interviewed. The following documents were obtained: LIC 500 Personnel Report, resident roster, monthly food menu, weekly food menu, special diet/special food request list, kitchen staffing schedule, resident council minutes (9/1/22) and hospice list. On 10/19/22, 2 additional staff were interviewed telephonically. During today's visit, a physical plant tour of the facility physical plant with focus on meal service and review of staffing schedules and file review. LPA interviewed Acting Administrator and obtained R9’s file documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221010131204
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 HACIENDA, THE
FACILITY NUMBER: 198603425
VISIT DATE: 03/08/2024
NARRATIVE
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Allegation: "Facility fails to provide residents with a nutritious diet." It is alleged that the facility serves prepackaged low-quality food. Based on interviews conducted staff stated that in the past (more than 1 year ago), the facility used to serve frozen prepackaged food. Administrator stated that when the current Dietary Director was hired (Sep .2021) they started buying and serving fresh vegetables, fruits, and proteins. The Dietary Director stated kitchen staff use approved dietary meal menus created and reviewed by the facility Registered Dietician (RD) once a month. Staff stated they have observed frozen meats be thawed and cooked, and presently the only prepackaged food items are mixed vegetables. Per staff interviews, residents eat most of the food that is served. However, the facility serves substitute food items if requested or when it is determined to be needed. In October 2022, there were 8 residents on mechanical soft, 10 residents on pureed diets, the rest of the residents were on a regular diet. Per record review, the facility provided copies of the monthly food menu that listed a balanced diet that meets the resident's needs. A total of 16 staff were interviewed, of which 4 stated that there were several times some residents were not fed their dinner because staff were very busy, therefore the residents that were asleep during dinner time were not awakened. A total of eight (8) residents were interviewed, of which the majority (6 residents) reported that they are served good quality delicious food. During today's visit, meal preparation was observed. The food appears to meet nutritional guidelines. There is insufficient evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.



Exit interview conducted with Acting Administrator Denise Downey. A copy of the report was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5