198603425-1-12-2022-28-AS-JHAA-C9X2N6-20211221163213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603425
Report Date: 12/21/2021
Date Signed: 01/12/2022 03:16:54 PM

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 HACIENDA, THE		FACILITY NUMBER:	198603425
ADMINISTRATOR:	PAOLI, FREDERICK		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 53	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Donnel Clark		TIME COMPLETED:	04:40 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	On 12/21/21 at 9:15am-Licensing Program Analyst (LPA) Hanna conducted a Post Licensing/Required 1 year, infection control visit. LPA met with Administrator, Donell Clark and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed (6) resident and (6) staff files. Facility has submitted a mitigation plan and the plan has been approved. LPA inspected 7 resident bedrooms (bedrooms: 5,10,19,20,22,26,27) throughout the community. Including but not limited to activity room, courtyard, kitchen Each apartment inspected, was observed to have smoke detector, bed, linen, dresser, light, and sufficient closet space. LPA toured the main kitchen and observed the space to be secured and all appliances in operating condition. There was a sufficient amount of perishable and non-perishable food, no expired items were observed. The common areas throughout the community had been toured: the activity room, dining room and courtyard were found to be clean and have the required furniture. Community was observed to have a centralized fire control system that appeared to be up to date and in operating conditions. Carbon Monoxide was found throughout the community and in working condition. Fire Extinguishers observed to be dated 8/2021 and placed throughout facility. LPA reviewed 6 resident files and observed all to have updated emergency contact information (LIC601). LPA reviewed 5 staff files and found all to have health screening on record. LPA reviewed residents' medications that were found to be logged/recorded through a MAR database- RX' are refreshed/deleted after medications are reordered. At the time that LPA entered the facility, LPA observed sign-in log and self-temperature thermometer directly outside of the entrance to the community. 809C Cont...

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT HACIENDA, THE	FACILITY NUMBER: 198603425
	VISIT DATE: 12/21/2021

NARRATIVE

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LPA observed:

- At 10:45am, no toilet paper, paper towels in bedroom # 22 (restroom). (technical advisory issued)
-At 11am, no toilet paper, paper towels and water temperature of 134.6 degrees Fahrenheit in bedroom #26(restroom).
-At 11:45am, water temperature was observed at 138.2 degrees Fahrenheit.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to the Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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
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: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(1)(2)

This requirement is not met as evidenced by: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as evidenced by: LPA observed hot water temperature measured at 134.6 degrees fahrenheit (room #26) and 138.2 degrees Fahrenheit (room #27)
	POC Due Date: 12/22/2021
	Plan of Correction
1 2 3 4	Administrator will submit a letter of certification indicating intent to adjust water temeprature to required range throughout entire facility. On 12/31/21- Administrator will submit a picture of gauge under running sink reflecting appropriate temperature- to CCL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Joseph Hanna	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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