198603425-2-24-2023-28-AS-MVAO-CPJQH4-20230302111031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603425
Report Date: 02/24/2023
Date Signed: 02/24/2023 04:26:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/28/2022 and conducted by Evaluator Kimberly Ramirez

COMPLAINT CONTROL NUMBER: 28-AS-20220128163928

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:	0	CENSUS: 48	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Administrator Donell Clark		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility abandoned resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit stemming from initial compliant visit dated 02/04/2022. LPA was met by Administrator Donell Clark and explained the reason of the visit.

The investigation consisted of: LPA conducted interview with Staff S1, tour of physical plant, LPA requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Resident 1 (R1) file, and copies of pertinent documents related to complaint allegation.

See LIC 9099-C for continuation of report…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20220128163928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT HACIENDA, THE	FACILITY NUMBER: 198603425
	VISIT DATE: 02/24/2023

NARRATIVE

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Allegation: “Facility staff abandoned resident.” It is alleged staff abandoned Resident R1 at local hospital. Staff S1 denied this allegation. After review of R1’s medical record, LPA observed documentation from R1’s primary care physician, indicating R1 is not to return to facility due to change of service needs. R1 was unable to be interviewed and LPA was unable to interview residents in care due to cognitive abilities.

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

An exit interview was conducted with Administrator Donell Clark. A copy of the report was issued.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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