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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 05/16/2024
Date Signed: 05/16/2024 07:08:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/14/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240514142948
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
UNANNOUNCEDTIME BEGAN:
07:54 AM
MET WITH:Wellness Director Jennifer LiefveldTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not provide adequate supervision resulting in resident eloping from facility.
Staff did not notify authorized representatives of an unusual incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 05/16/2024, regarding the above allegations. LPA Ramirez was met by Wellness Director Jennifer Liefveld and Marketing Director Donell Clark and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident Roster (LIC 9020), Staff Roster (LIC 500), Staff#1 - 5 interviews(S1 – S5), copy of Staff#3-5 (S3-S5) Personnel Record (LIC 501), interview of Resident#1 (R1), interview with R1’s responsible party, interview with Witness#1 (W1), Resident# 1-(R1) review of resident records, copies of Resident#1(R1) Physician’s Report dated 03/10/2023, R1’s Identification and Emergency Information form, R1’s Admission Agreement dated 07/27/2023, and physical plant tour.

SEE 9099-C for continuation.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20240514142948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/16/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Facility staff did not provide adequate supervision resulting in resident eloping from facility- It is alleged R1 left the facility unassisted and facility staff were not aware R1 left the facility without constant supervision. Five (5) out of the five (5) staff interviewed confirmed this allegation. Interview with R1 confirmed this allegation. Interviews with staff revealed R1 may not leave the facility unassisted. Review of R1’s physician report dated 03/10/2023, confirms R1 may not leave the facility unassisted. On May 10,2024, R1 was picked up by a transportation service between noon and 1pm. An unnamed/unknown transportation driver alerted facility staff that they were at the facility to pick up R1. Facility staff (S3) alerted via walkie talkie to the other facility staff, that someone was at the facility to pick up R1. Facility staff (S3) allowed R1 to leave the facility without confirming who R1 was being released to and who would be assisting R1 while out in the community. R1 was able to get to their destination in the community and was out in the community without facility assistance or any other known assistance. Interview with W1 revealed the driver of the transportation service did not provide guided assistance to R1 while out in the community on 05/10/24. R1 was returned to the facility via the same transportation service several hours later. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. LPA Ramirez will issue an immediate $500 dollar civil penalty due to absence of supervision on 05/10/24. LPA Ramirez will issue Type A deficiency.

Staff did not notify authorized representatives of an unusual incident. - It is alleged the facility staff did not notify this licensing agency, R1’s responsible party or conservator, of R1’s wandering away from the facility unsupervised on 05/10/2024. It was revealed during staff interviews that facility staff became aware that R1 left the facility unsupervised on 05/13/2024. Interview with R1’s responsible party revealed no phone was made to R1’s responsible party on 05/11/2024 to inform them that R1 wandered away from the facility unsupervised. R1’s responsible party was notified of on 05/16/2024 via telephone. This licensing was not notified via telephone on 5/11/24. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.LPA Ramirez will issue Type B deficiency.

Exit interview was conducted. A copy of this report, 9099-D, LIC 421M 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20240514142948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
05/17/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal
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 to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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 assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.The licensing agency may require any facility
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Licensee failed to ensure staff was competent to provide services necessary to meet R1s needs. Licensee will retrain staff on this regulation and re-train staff on R1's needs and services. Proof of retraining is required by 5/30/24. Certified plan to address this POC must be submitted by 05/17/24.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20240514142948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
05/30/2024
Section Cited
CCR
97705(k)(7)
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87705 Care of Persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:
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The report shall be made by telephone no later than the next working day and in writing within seven calendar days.
This requirement was not met as evidence by:
Facility staff did not notify this licensing agency, and R1's responsible party via telephone within 1 business day
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(7)For each incident in which a resident wanders away from the facility
unsupervised, the licensee shall report the incident to the licensing agency, the resident’s conservator and/or other responsible person, if any, and to any family member who has requested notification.
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of 05/13/24.
Licensee will re-train staff on this regulation and send proof of re-training by 05/30/24.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 4