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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603425
Report Date: 07/12/2022
Date Signed: 07/12/2022 11:28:44 AM


Document Has Been Signed on 07/12/2022 11:28 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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:68CENSUS: DATE:
07/12/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donell Clark-Executive Director TIME COMPLETED:
11:30 AM
NARRATIVE
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Araceli Ramirez, Regional Manager, Christine Yee, Licensing Program Manager and Christine Wong, Licensing Program Analyst, conducted an informal office meeting with Donell Clark, Executive Director and Shelley Li, Regional Director of Operations with West Bay Senior Living at the Monterey Park Adult and Senior Care Office. The purpose of the visit was to discuss the following:

• Reporting requirements -The facility did not report the Covid-19 outbreak, power outage the facility and the staff shortages

• Staffing Shortages- Staff calling out due to Covid-19 and employment agency staff cancelling assignments at the last minute.

• Clarify ownership changes – Determine the new owners and the percentage in ownership change and the current management company responsible for the day to day operations.

• Administrator – determine who the current Administrator is and when a change in administrator occurred.

A copy of Title 22, Section 87211 Reporting Requirements was provided during the informal office meeting.

Exit interview conducted with Administrator Donell Clark and a copy of this report provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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