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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:10:28 PM


Document Has Been Signed on 10/20/2022 01:10 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 HACIENDA, THEFACILITY NUMBER:
198603567
ADMINISTRATOR:CLARK, DONELLFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 52DATE:
10/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donell ClarkTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Glenn Trueman conducted a pre licensing visit at Claremont Hacienda due to a change in ownership.
There are currently 52 residents living in the facility. The fire clearance for was granted on 07/25/22.. The fire clearance has been approved for 40 bedridden residents with a total capacity of 68.
The physical plant was toured and the following was observed.
As part of the Pre-licensing inspection LPA toured the entire facility, inside and out. The facility consists of one large building with Wings A, B, C and D.
The inspection consisted of 8 resident bedrooms, bathrooms, kitchen, dining area, activity room, medication room, and indoor/outdoor activity areas.
LPA toured Wing A Rooms 10 and 17. Wing B Rooms 5 and 11. Wing C Rooms 23 and 26 and Wing D Rooms 28 and 30.
Hot water temperature measured between 105 and 120 F. in rooms checked in Wings A, B and C.
In Wing D. hot water temperature was not between 105F. and 120F. measuring 73.2 in Room 30.
The bathrooms are clean and operational with grab bars and non-skid surface/mats in place. LPA observed an adequate food supply consisting of at least 2 days of perishables and 7 days of non-perishables. The kitchen appeared to be within Title 22 Regulations. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in secured cabinets and closets and inaccessible to residents. The facility has central air and heating accommodations. All exits doors are equipped with a delayed egress alarm system. The smoke alarms are hardwired/interconnected and appear to be operational. Carbon monoxide detectors are battery operated and appear to be operational.
Component III: Conducted at the Pre-Licensing visit.
LPA observed that the facility does not meet Title 22 Regulations. The following are corrections needed by 10/27/22. LPA will conduct a follow visit to ensure all corrections are made.
Ensure that Hot water temperature measures between 105F. and 120F. in Wing D.
Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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