198603567-3-7-2024-28-AS-RORN-D3QVKY-20240326163107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:40:26 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
03/09/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230309152418

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:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Denise Downey-Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident developed sepsis while in care due to UTI.
Resident fell while in care resulting in fracture.
Staff did not respond to resident's call in a timely manner.
Staff did not inform resident's authorized representative of incident.

INVESTIGATION FINDINGS:

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Licensing Program Aalyst (LPA) V. Maldonado made an unannonced visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator Denise Downey and explained the purpose for the visit.

On 3/10/23 LPA Maldonado conducted an initial visit to the facility for the purpose of conducting a health and saftey check. During the visit, LPA obtained a copy of staff and resident rosters for January 2022-June 2022, conducted a tour of physical plant and common areas, observed the food supplies, and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns.

The following allegations were investigated by the licensing agency's Investigation Bureau (IB) investigator, Edward Hector: 1.) Resident developed sepsis while in care due to UTI. 2.) Resident fell while in care resulting in fracture.
(Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230309152418

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: 03/07/2024

NARRATIVE

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IB investigator Hector's investigation consisted of the following: Interviews conducted with Staff 1-2 (S1-S2) and Residents# 2-5 (R2-R5). IB Investigator also reviewed R1's facility file and medical records. IB Investigator was unable to interview Resident#1 (R1) due to R1 being deceased.
The investigation revealed the following:

Regarding allegation: Resident developed sepsis while in care due to UTI.
It is alleged that R1 had a fall at the facility that resulted in hospitalization, where the hospital also diagnosed R1 with sespsis due to a Urinary Tract Infection (UTI). Per IB Investigator Hector's interviews, (2) of (2) staff denied having knowledge R1 developing sepsis while in care due to a UTI. Staff stated R1 had a history of sepsis and UTI's prior to admission to the facility. (4) of (4) residents interviewed could no corroborate the allegation. Per R1's Pre-Placement Report and Physician's Report, it was confirmed that R1 had a history of sepsis and UTI's. Per medical records obtained by Investigator Hector, it was noted that R1 presented to the hospital with symptoms of sepsis, but it was documented that it was unclear what the cause of the sepsis was. Therefore, this allegation is Unsubstantiated.

Regarding allegation: Resident fell while in care resulting in fracture.
It is alleged that R1 had prior falls at the facility, and on 04/04/22, R1 had a fall at the facility which resulted in a fracture. Per IB Investigator Hector's interviews, (2) of (2) staff denied having knowledge of falls prior to the 04/04/22 fall. (4) of (4) residents interviewed could not corroborate the allegation. Per incident report dated: 04/08/22, R1 complained of pain to staff. Upon staff assessment of R1, R1 reported to have fallen while going to the bathroom and was observed to have a bruising in the area with pain. 911 was called immediately and R1 was taken to the hospital for evaluation. There is no indication that staff neglected the resident or that there was lack of care or supervision. Therefore, this allegation is Unsubstantiated.

During today's visit, LPA Maldonado investigated the following allegations: 3.) Staff did not respond to resident's call in a timely manner. 4.) Staff did not inform resident's authorized representative of incident. LPA Maldonado's investigation consisted of the following: LPA obtained a copy of the resident and staff rosters, and the following records for Resident# 1 (R1): Facesheet, Pre-Placement Appraisal, Physician's Report, Needs and Services Plan, facility internal notes, and all incident reports for R1. LPA also conducted interviews with Residents#2-5 (R2-R5) and Staff#1-5 (S1-S5). LPA was unable to interview R1 due to R1 being deceased.

(Report continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230309152418

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: 03/07/2024

NARRATIVE

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The investigation revealed the following:

Regarding allegation: Staff did not respond to resident's call in a timely manner.
It is alleged that prior to the documented fall on 04/04/22, on an unknown date at about 3:00AM, R1 had fallen in R1's room and called out to staff for help for a long time, but staff never came to assist R1. Per staff interviews, (5) of (5) staff denied having knowledge of R1 falling at the facility prior to the documented fall on 04/04/22. Staff stated that if any resident were to call for help, whether using the call button or verbally, they would be assisted right away. (1) of (4) residents denied the allegation. R2 stated that R1 only had one fall at the facility and the staff assisted R1 right away. R1 was then taken by the paramedics. (3) of (4) other residents interviewed could not corroborate the allegation, but stated that staff respond to all resident's calls and requests right away and staff are helpful. Therefore, this allegation is Unsubstantiated.

Regarding allegation: Staff did not inform resident's authorized representative of incident.
It is alleged that prior to the documented fall on 04/04/22, on an unknown date at about 3:00AM, R1 had a fall at the facility and R1's authorized representative was not notified of the incident. Per staff interviews, (5) of (5) staff denied having knowledge of R1 falling at the facility, prior to the documented fall on 04/04/22. Staff stated that resident's authorized representatives are notified of any incidents occurred at the facility, immediately. (4) of (4) residents interviewed could not corroborate the allegation. Therefore, this allegation is Unsubstantiated.

Based on the LPA's record review, interviews, and observations, the investigation revealed: 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.

Per California Code of Regulations, Title 22, and the Health and Safety Codes, no deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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