198603567-1-18-2024-28-AS-RORN-CZTV3W-20240125150527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:27:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240111082233

FACILITY NAME:	CLAREMONT HACIENDA, THE		FACILITY NUMBER:	198603567
ADMINISTRATOR:	CLARK, DONELL		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 49	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Donell Clark		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not assist resident with incontinence needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Administrator Donell Clark and explained the reason for the visit.
The investigation consisted of the following: LPA obtained copies of the resident and staff roster.
Administrator was interviewed at 9:50 AM.
Resident R 1 was interviewed at 10:15 AM.
Interview was conducted with Staff S 1 at 10:30 AM.
Interview with Staff S 2 was conducted at 10:45 AM.
Interviews were conducted with Resident's R 2 - R 6 from 10:45 AM to 11:30 AM.
LPA reviewed R 1's file and Physican's Report, Appraisal Needs and Services Plan, Identification and Emergency Information document was submitted.
LPA toured the facility and inspected Rooms 4, 6, 9, 14,16, 17 which all had required furnishings and were clean and did not have any odors or urine smell.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20240111082233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 198603567
	VISIT DATE: 01/18/2024

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

In regards to the allegation Staff do not assist resident with incontinence needs, based on interviews conducted and information gathered it was revealed by R 1 that the staff are good.
Said they change his diaper and there is no problem at all.
Said staff are very good.
Interviews with 6 of 6 resident's who have not heard of anyone left in their diaper all nite.
All 6 stated the staff are great and will assist with diaper changes and any other need they may have.
Spoke with staff who stated they do assist R 1 and other resident's with diaper changes.
Staff stated that R 1 at times is resistant and does not want to be changed and will hit and bite them.
Staff stated they will keep trying and R 1 and all residents are never left in diaper all nite long.
Administrator stated that police got a complaint call and they were at facility and observed R 1 at meal time and observed his room and told the administrator everything is good.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2