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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 08/05/2024
Date Signed: 08/05/2024 05:35:31 PM


Document Has Been Signed on 08/05/2024 05:35 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:
08/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Administrator Denise DowneyTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 08/05/2024, stemming from initial complaint investigation conducted on 08/05/2024. LPA Ramirez was greeted by Administrator Denise Downey.

Case Management-Deficiencies findings:

LPA Ramirez was conducting a resident record review stemming from initial complaint investigation conducted on 08/05/2024. LPA Ramirez was reviewing Resident#1 (R1) Physician’s Report (dated 09-25-2023) when it was revealed R1 has a primary diagnosis of a mental disorder that is unrelated to dementia. This facility is approved for delayed egress devices on exterior door or perimeter fence gates. R1 was accepted into the facility on 12/08/2021. Per Title 22, Division 6 Chapter 8 Article 12. Dementia- 87705 (k)(9):



(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates:
(9) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia.


On 07/28/2024, R1 voluntarily ended their tenancy at the facility and relocated as of 08/03/2024. Licensee will retrain staff on above regulation and send proof of retraining by 08/19/2024.


Deficiencies are being cited. 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: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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 08/05/2024 05:35 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: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2024
Section Cited
CCR
87705(k)(9)

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(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates:
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associated with dementia and the facility is approved for delayed egress.
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(9) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. This requirement was not met as evidence by: R1 was accepted and resided at the facility with a primary diagnosis of a mental disorder not
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R1 relocated on 08/03/2024. *This clears 24 POC.* Licensee will retrain staff on this regulation and provide proof of retraining by 08/19/2024.

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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: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2