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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 05/16/2024
Date Signed: 05/16/2024 06:58:04 PM


Document Has Been Signed on 05/16/2024 06:58 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: 47DATE:
05/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Wellness Director Jennifer LiefveldTIME COMPLETED:
05:00 PM
NARRATIVE
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CASE MANAGEMENT FINDINGS:

LPA Ramirez conducted case management deficiencies visit on 05/16/24 due to observations during facility tour, in regard to a complaint investigation conducted on 05/16/2024. During tour of the facility grounds LPA Ramirez made the following observations:

· Delay egress doors located in wing A and wing C were not operating to their original design when LPA Ramirez tested delay egress alarm. At 8:03 am, LPA Ramirez pushed on exit door (#1) located in wing C, release bar for 18 seconds and no alarm was heard and the door did not open. LPA Ramirez pushed on exit door (#2) located in wing C, release bar for 25 seconds and no alarm was heard and the door did not open. LPA Ramirez pushed on exit door (#3) located in wing A, release bar for 18 seconds and no alarm was heard and the door did not open. According to Marketing Director Donell Clark, exit door located in wing A is temporarily disabled due to construction being done in the facility. Facility staff was unaware at the time of LPA’s visit that exit doors 1& 2 in wing C were not operating to their original design. LPA Ramirez did observe facility staff key in a numeric code into exit door and exit door opened. LPA Ramirez will issue Type B deficiency based on observation.

· At 8:17 am, LPA Ramirez toured rooms 11 and 19 and observed these rooms to under construction. According to Marketing Director Donnel Clark these two rooms experienced leaks during the recent storms and the roofing and drywall in these rooms needed to be replaced. Construction began 1 month ago and is currently in phase 2 of completion. LPA Ramirez did not observe a building permit and per Marketing Director Donell Clark, he can not recall if the facility applied for a building permit. LPA Ramirez will issue Type B deficiency.

Exit interview was conducted. A copy of this report, 809-D, and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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


Document Has Been Signed on 05/16/2024 06:58 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee will repair doors and send proof of invoice by 05/23/2024.
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This requirement was not met as evidence by:
2 Delay egress doors were not working to their original design during tour.
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Type B
05/23/2024
Section Cited
CCR87305(a)

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87305 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement was not met as evidence by:
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Licensee shall obtain a building permit and send proof by 05/23/24.
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No building permit was observed during tour.
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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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2