198603425-9-29-2021-28-AS-WSHO-CDQQ9B-20220422115801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603425
Report Date: 09/29/2021
Date Signed: 09/29/2021 03:39:31 PM

Unsubstantiated

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
09/23/2021 and conducted by Evaluator Joe Katrdzhyan

COMPLAINT CONTROL NUMBER: 28-AS-20210923151911

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: 48	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Associate Executive Director / Jennifer Liefveld Executive Director / Donell Clark		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.

Resident restrained for an extended period of time.

Resident's needs not met due to inadequate staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs met with Executive Director / Donell Clark and Associate Executive Director / Jennifer Liefveld who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Resident sustained unexplained bruising while in care, Resident restrained for an extended period of time and Resident's needs not met due to inadequate staffing".

During today's visit, LPA conducted interviews of various persons to include the Associate Executive Director, Staff members 1 - 4 (S1 - S4) and Residents 2 - 4 (R2 - R4). Resident 1 (R1) was hospitalized on 9/23/21 and remains at Pomona Valley Hospital due to a decline in her health condition. A written statement was obtained from LVN 1 as she worked the night shift on 9/22/21. Also, copies of the following documents were obtained and reviewed in reference to R1;
• Identification and Emergency Information Sheet • Preplacement Appraisal Information • Functional

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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-20210923151911

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: 09/29/2021

NARRATIVE

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Capability Assessment • Physician's Orders • Physician's Report • Inter Facility Report • Appraisal/Needs and Services Plan • Shower/BM Care Log • Log for Resident Room Checks

The investigation revealed the following;

Allegation: Resident sustained unexplained bruising while in care. The details of this allegation states that R1 has really bad bruising on her arms and staff have informed that R1 does it to herself.

Based on interviews conducted and record reviews, LPA learned that R1 has a diagnosis of dementia and recently her condition declined rapidly causing her to be hospitalized on 9/23/21 for refusing to eat, refusing to take medications, having aggressive behaviors towards staff and causing self harm. It was noted on the Physician's Order dated 9/23/21 that "R1 to be taken to skilled nursing facility. If no bed available to be sent out 911 due to rapid decline". On 9/16/21, the treating physician ordered Clonazepam for actively acting out verbally and aggressively towards staff. On the Inter Facility Report dated: 8/11/21, it took four caregivers to assist R1 with her shower as R1 was being combative and trying to bite staff. Statements obtained corroborated that the bruising sustained on R1's arms were as a result of her aggressive behaviors towards self, staff and by hitting her arms against chairs and walls. Based on interviews conducted and record reviews, there is insufficient evidence to support the allegation of Resident sustained unexplained bruising while in care.

Allegations: Resident restrained for an extended period of time and Resident's needs not met due to inadequate staffing. The details of these allegations state that on 9/22/21, at approximately 3:45PM, R1 was observed to be strapped to her wheelchair and R1 was sitting in her feces and did not know how long she had been sitting there. Also, there were two caregivers helping on the floor for 46 residents. Residents are not being fed, repositioned and changed and nails and fingernails are not being maintained.

Based on interviews conducted, the statements obtained did not present any concerns of residents not being fed, repositioned, changed or facility having inadequate staffing. Interviews conducted with staff and residents denied residents not being fed. LPA learned that during the AM shift (7am - 3pm), there are normally 4 - 5 staff on duty (1 Med Tech, 1 Nurse and 2 - 3 caregivers). During the PM shift (3pm - 11pm), there are normally 4 staff on duty (1 Med Tech/Nurse and 2 - 3 caregivers) and during the Noc shift there are normally 2 - 3 staff on duty (1 Med Tech and 1 - 2 caregivers). During the evening of 9/22/21, there were four staff

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210923151911

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: 09/29/2021

NARRATIVE

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working at the facility (1 Nurse, 2 Caregivers and a Staff from a temp agency). Per the Associate Executive Director, the facility is working with Home Care Staffing agency in the event that a staff member calls in sick or facility is in need of additional help. Statements obtained denied facility having inadequate staffing. In reference to resident diapers not being changed, the facility keeps a log for the AM, PM and Knock shifts for resident showers and BM (bowel movement) schedules and how often the residents are changed/cleaned. Facility also keeps a log of how often staff check on residents, which is done every two hours. Statements obtained from staff were consistent and corroborated that Residents are checked on every two hours and diapers are changed for residents as needed. According to the Physician's Report for R1, R1 is listed as needing assistance - direction with toileting needs and the facility has noted in R1's Appraisal and Needs and Services Plan that staff will change R1 every 2 hours or as needed. Interviews conducted denied staff strapping R1 to her wheel chair for an extended period of time. The gait belt is used during transfers and when R1 is tired to prevent R1 from falling out of her wheel chair. There is a written order dated 9/20/21, for the use of a gait belt for R1. In reference to the fingernails and toe nails not being maintained for residents, statements obtained stated that the facility nurse is in charge of cutting the fingernails of residents and a Podiatrist visits the facility at least once every two months in order to maintain the toe nails for residents. Based on interviews conducted, record reviews and LPAs observations, there is insufficient evidence to support the allegations of Resident restrained for an extended period of time and Resident's needs not met due to inadequate staffing.

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

An exit interview was conducted and a copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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