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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:36:42 PM


Document Has Been Signed on 12/05/2023 02:36 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 HACIENDA, THEFACILITY NUMBER:
198603567
ADMINISTRATOR:CLARK, DONELLFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 53DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Administrator-Donell ClarkTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Deficiencies visit on 12/05/23. LPA met with Administrator Donell Clark and discussed the purpose of today’s visit. On 12/05/23 LPA Ramirez conducted a Case Management POC, stemming from subsequent annual inspection that was conducted on 10/13/23.

Case Management Deficiencies findings:

During today’s visit, LPA Ramirez issued the following citation: 1569.625(b)(1)(2) Staff training; legislative findings; (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

LPA Ramirez reviewed six (6) caregivers (S1- S6) personnel training records. Staff#3 (S3) hired on 8/14/23- training record did not reflect 6 hours specific to dementia care and shall be completed within the first four weeks (9/11/23) of employment. Staff#4 (S4) hired on 6/20/23- training record did not reflect 6 hours specific to dementia care and shall be completed within the first four weeks (7/18/23) of employment.

Staff#1,2,5,6 (S1, S2, S5, S6) training record did not reflect 20 hours annually, eight hours of which shall be dementia care training and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.

LPA Ramirez will issue two (2) deficiencies based on record review.

Exit interview conducted, this report, 809-D, appeal rights and a copy of this report were provided to Donell Clark.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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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Document Has Been Signed on 12/05/2023 02:36 PM - It Cannot Be Edited

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 HACIENDA, THE
FACILITY NUMBER: 198603567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
HSC
1569.625(b)(1)

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(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training.
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This requirement was not met as evidence by:S3 &S4 did not have documented training hours. Licensee to provide proof of staff training as noted on this regulation to LPA Ramirez by POC due date. Licensee will certify plan to address how Licensee will ensure this regulation is met in the future.
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A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents.
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 The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
Type B
12/19/2023
Section Cited
CCR1569.625(b)2)

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(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall
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 Licensee to provide proof of staff training as noted on this regulation to LPA Ramirez by POC due date. Licensee will certify plan to address how Licensee will ensure this regulation is met in the future.
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be specific to postural supports, restricted health conditions,and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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This requirement was not met as evidence by:
Staff#1,2,5,6 (S1, S2, S5, S6) training record did not reflect 20 hours annually, eight hours of which shall be dementia care training and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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