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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 02:33:38 PM


Document Has Been Signed on 12/05/2023 02:33 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: 52DATE:
12/05/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Donell Clark-AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management POC (Plan of Correction) visit on 12/5/23. LPA met with Administrator Donell Clark and discussed the purpose of today’s visit. On 11/28/23 LPA Irra conducted a Case Management POC, stemming from subsequent annual inspection that was conducted on 10/13/23.

History of Case Management POC visits:

On 10/27/23: Civil Penalties from 10/21/23 through 10/26/23 issued in the amount of $ 600.00.

On 11/13/23: Civil Penalties from 10/27/23 through 11/12/23 issued in the amount of $ 1,700. 00.

On 11/28/23: Civil Penalties from 11/13/23 through 11/27/23 issued in the amount of $ 1,500. 00.

On 12/05/23 (today): Civil Penalties from 11/28/23 through 12/4/23 were assessed.

During today’s visit, LPA Ramirez issued the following citation: 87405(f) Administrator - Qualifications and Duties (f) The administrator in facilities licensed for fifty (50) or more shall have two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency. Based on record review, the licensee did not comply with the section cited above in (1) out of (5) staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. Per record review, current designated Administrator/S-1 appears not to have the required qualifications and duties noted on this regulation. Per S-1’s record review and interview, S-1 could not provide additional documentation of at least three years of experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency. Original Plan of Correction (due 10/20/23): Administrator to submit proof to reflect that administrator meets the qualifications noted in this regulation or provide new qualified administrator with the specified qualifications noted above to LPA Irra by POC due date. As of today, this deficiency has not been corrected. Civil Penalties are hereby being assessed from 11/28/23 through 12/04/23 in the amount of $700.00. Civil Penalties will continue to be assessed until the corrections have been made.

Exit interview conducted, LIC 421FC/Civil Penalties forms, 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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