<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 12/13/2023
Date Signed: 12/13/2023 10:47:50 AM


Document Has Been Signed on 12/13/2023 10:47 AM - 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:
12/13/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Administrator Donell ClarkTIME COMPLETED:
10:04 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/13/23, an informal meeting was held at the Monterey Park Adult and Senior Care Regional Office. The purpose of this office meeting was to discuss civil penalties and uncleared deficiencies issued at the facility – CLAREMONT HACIENDA, THE -198603567.

Present in today’s meeting: Licensing Program Manager – Tony Vasallo, Licensing Program Analyst – Kimberly Ramirez, Licensing Program Analyst – Elizabeth Irra, facility administrator – Donnell Clark, Jennifer Liefveld-Wellness Director and licensee representative – Laurie McConnell, Principal, Vice President of Operations, Ally Senior Living-via phone.

During the meeting, the following were addressed:


· ANNUAL VISIT - 10/10/23
· ANNUAL VISIT CONTINUATION- 10/13/23: Deficiencies issued.
· POC VISIT- 10/27/23: Civil Penalties from 10/21/23 through 10/26/23 issued in the amount of $ 600.00.

· POC VISIT -11/13/23: Civil Penalties from 10/27/23 through 11/12/23 issued in the amount of$1,700.00.

· POC VISIT-11/28/23: Civil Penalties from 11/13/23 through 11/27/23 issued in the amount of $1,500.00.

· POC VISIT- 12/05/23: Civil Penalties from 11/28/23 through 12/04/23 issued in the amount of $ 700.00.

· Administrator or Licensee has not provided administrator qualifications that meet 87405(f) since last visit 12/05/2023.

· Administrator or Licensee has not provided documented training that staff has completed required training per 1569.652(b)(1)(2) since last visit 12/05/2023 and 10/13/23.

· How will the facility get back into compliance?

· Pending fingerprint clearance for 16 staff.

See 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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
VISIT DATE: 12/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The licensee agreed to do the following:

· All staff (including MedTech, Caregivers) and will have required training per 1569.652(b)(1)(2) by 01/03/2024.
· The licensee will clear POC for 87405(f) administrator qualifications by 01/10/2024.
· The licensee will address 16 staff that are pending fingerprint clearance by 01/03/2024.

Report was provided via email.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2