198603425-8-11-2022-28-AS-FFIS-CHT4VQ-20220830192641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603425
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:44:40 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
06/28/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220628100738

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: 50	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Amber King, resident care coordinator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility does not follow COVID-19 protocol.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint investigation for the allegation listed above. An initial complaint visit was conducted on 06/30/22. During today’s visit, LPA met with Amber King, resident care coordinator (RCC). LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA interviewed staff from staff#1 to staff#4 and reviewed records. LPA obtained copies of resident roster, staff roster, COVID test results copies date (6/25/22- 6/28/22), staff work schedule June 2022- July 2022 and incident report regarding COVID cases, reported on 6/30/22.

Regarding allegation, "Facility does not follow COVID-19 protocol," it was alleged that facility required staff who tested positive for COVID 19 to return to work at the facility. During the investigation, LPA Tao interviewed Administrator and two staff. (-continued in LIC 9099C-)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20220628100738

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: 08/11/2022

NARRATIVE

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Interviews revealed three (3) out of three (3) staff reported staff#3 returned to work within five (5) days after being confirmed as positive for COVID 19 without Staff #3 being re-tested for COVID 19 prior to staff #3 returning to work or the day staff #3 returned to work. Staff file reviews revealed that staff#3 who tested positive for COVID 19 on 06/25/22 was vaccinated and received the booster. Per Provider Information Notice (PIN) 22-09-ASC, facilities that have critical staffing shortages and may have vaccinated and boosted staff who are COVID positive return to work with less than five (5) days of isolation may return to work if the positive staff is provided with a diagnostic test for COVID 19 on the day of return to work or within twenty-four (24) hours prior to returning to work and shall staff placement shall be prioritized by the most recent test results. The investigation revealed that the facility did not re-test Staff#3 within twenty-four (24) hours or on the day Staff#3 returned to work on 06/27/22. Per the investigation Staff#3 was re-tested on 06/29/22, which is two days after returning to work. Therefore, the facility failed to follow the COVID 19 protocols.

Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted with Amber King. Appeal rights and copy of LIC 9099s report were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220628100738

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: 08/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee will review Title 22 Regulations, Section 87468.1 and PIN 22-09-ASC and submit a written plan detailing how Licensee would ensure that Licensee will follow regulations and PIN by POC due date.
	8 9 10 11 12 13 14	Per interviews conducted, administrator did not re-test staff who confirmed with COVID + on the day of return or within 24 hours. Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care	8 9 10 11 12 13 14
	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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