198603567-8-5-2024-28-AS-TVAO-D8BPVK-20240820113916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 08/05/2024
Date Signed: 08/05/2024 05:16:56 PM

Unsubstantiated

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
08/01/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240801115947

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: 47	DATE:	08/05/2024
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Wellness Director Cassandra Crowley		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff withhold food from residents.
Licensee falsified rate increase reason provided to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/05/2024 regarding the above allegations. LPA Ramirez was greeted by Wellness Director Cassandra Crowley and explained the purpose of the visit. Administrator Denise Downey arrived shortly after to assist with tour.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 4 interviews (S1 – S4), Attempted interview of Resident#1 (R1), Resident#2-4 (R2-R4) interviews, copies of Resident#1 (R1) Physician’s Report, Identification and Emergency Information, Admission Agreement, Notification of Monthly Rate increase dated 06/01/2024, Sysco food invoices for 7/2024, and physical plant tour.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240801115947

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: 08/05/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegations: Staff withhold food from residents - It is alleged that staff withhold snacks like Flaming Hot Cheetos and soda from residents. Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. On 08/05/2024, LPA Ramirez conducted a tour of the facility kitchen. LPA Ramirez toured all areas of the kitchen and dinning room. LPA Ramirez observed a vending machine located within the facility employee breakroom. LPA Ramirez observed various snacks including Flaming Hot Cheetos and cans of soda. Per staff interviews, these snacks may be purchased by staff, visitors or residents. LPA Ramirez observed this vending machine to be accessible to staff and residents. LPA Ramirez observed Sysco foods invoice for the month of 7/2024. LPA Ramirez observed the facility ordered 2x-Doritos (242.5 oz) and 1x-Ruffles chips (81.6 oz). 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.

Licensee falsified rate increase reason provided to residents - It is alleged the facility falsified the reason why rent was increased for R1. Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. During record review, it was revealed the facility notified R1 of rental rate increase (dated 06/01/2024) and became effective 08/01/2024. LPA Ramirez observed this notification of rate increase to contain date letter was provided, effective date of increase and a general description for rate increase. 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.

No deficiency was cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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