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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603441
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:41:34 PM

Document Has Been Signed on 08/11/2022 04:41 PM - 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 CARE HOME LLCFACILITY NUMBER:
198603441
ADMINISTRATOR:CANLOBO, MARGIE D.FACILITY TYPE:
735
ADDRESS:2926 GRAMERCY STREETTELEPHONE:
(626) 689-3079
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Margie Canlobo, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Administrator, Margie Canlobo, who assisted with visit. The facility is to serve (3) non-ambulatory and (1) ambulatory Developmentally Disabled individuals, age 18 through 59 years old. Annual fees are current. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

All current clients were placed by San Gabriel/Pomona Regional Center. Administrator certificate is current, expires on 12/22/22. Annual fees are current.



During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

This is a single story home which consists of four (4) bedrooms, two (2) bathrooms, kitchen with a dining area, living room, laundry room, and attached garage. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Hot water temperature was measured at 107.1 degrees Fahrenheit. (-Continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
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.

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 CARE HOME LLC
FACILITY NUMBER: 198603441
VISIT DATE: 08/11/2022
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Smoke detectors are dual which combined with carbon monoxide detectors are operable. Medications are centrally stored and locked.

Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 07/11/22.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted.

This report was discussed and provided to Administrator, whose signature on this form confirm the receipt of these documents. Appeal right was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2022 04:41 PM - It Cannot Be Edited


Created By: Bonnie Tao On 08/11/2022 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT CARE HOME LLC
FACILITY NUMBER: 198603441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Trash and broken cement pieces were piled up in the backyard.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee would remove the trash and broken cement pieces from the backyard. Administrator will provide pictures of the backyard after those items been removed to Licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Bonnie Tao
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


LIC809 (FAS) - (06/04)
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