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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603441
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:02:45 PM

Document Has Been Signed on 08/10/2023 12:02 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
GREATER LA AC/SC, 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: 4DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grace Peligman/S-1 and Margie Canlobo/S-2TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Grace Peligman/S-1 and discussed the purpose of today’s visit. Margie Canlobo (Administrator/S-2) arrived at approximately 9:15 A.M..

This home has 4 bedrooms, 2 full bathrooms, kitchen, dining area, living room, laundry and an attached garage. All clients receive case management services provided by San Gabriel Pomona Regional Center. Fire Clearance is for (4) non-ambulatory clients. Each client has their own bedroom. (3) out of (4) clients are over the age of 59.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 08/02/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms were tested and operable. Carbon monoxide detector was tested and is operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured at: 111.3* in kitchen and 108.5* in the hallway restrooms.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT CARE HOME LLC
FACILITY NUMBER: 198603441
VISIT DATE: 08/10/2023
NARRATIVE
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Margie Canlobo expires 12/22/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) and Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.

Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, Individual Program Plan (IPP), House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Per Administrator, there are no clients on modified/special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are (0) clients with restricted health condition plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

Deficiencies cited. Refer to LIC 809D.

Exit interview, appeals rights and a copy of this report was provided to Margie Canlobo (Administrator/S-2)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/10/2023 12:02 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 08/10/2023 at 11:34 AM
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: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Margie Canlobo did not have an HIV nor TB training on file.
POC Due Date: 08/17/2023
Plan of Correction
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Administrator to submit proof of HIV and TB enrollment to LPA Irra by POC due date noted above.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/10/2023 12:02 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 08/10/2023 at 11:39 AM
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: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)
(c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: (1) Completed Functional Capabilities Assessment, required by Section 80069.2. (2) Completed Needs and Services Plan, required by Section 85068.2. If one or more age-related care needs are identified by the provider or the referring source, the licensee shall ensure that the Needs and Services Plan specifies how such need(s) will be addressed. (3) Documentation of a medical assessment, signed by a physician, made within the last year. (4) A letter of support from the person's conservator with placement authority, if applicable. (5) Letters of support, if any, from the person's placement officer, social worker, and/or mental health professional, if applicable, documenting that the Adult Residential Facility is the most appropriate setting for the person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (3) of (4) files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. Per file reviews, C-2 is the most recent client admitted that is above the age of (59).
POC Due Date: 08/24/2023
Plan of Correction
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Administrator to submit an age exemption request for C-2 (with required documentation noted above) to LPA Irra by POC due date.

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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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