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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:26:53 PM


Document Has Been Signed on 10/27/2022 12:26 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
CCLD Regional Office, 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: 52DATE:
10/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Donell ClarkTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Glenn Trueman conducted a continuation pre licensing visit at Claremont Hacienda due to a change in ownership. Purpose of today's visit is to see if corrections were made from original visit conducted on 10/20/2022.
There are currently 52 residents living in the facility. The fire clearance for was granted on 07/25/22. The fire clearance has been approved for 40 bedridden residents with a total capacity of 68.
The physical plant was toured on initial visit 10/20/2022 and hot water temperature measured between 105F. and 120 F. in rooms checked in Wings A, B and C.
In Wing D. hot water temperature was not between 105F. and 120F. measuring 73.2 in Room 30.
LPA observed that the facility did not meet Title 22 Regulations. The following corrections were needed by 10/27/22:
Ensure that hot water temperature measures between 105F. and 120F. in Wing D.

At todays visit 10/27/2022 in Wing D Room 27 hot water temperature measured 105.2 F. in Room 27 and in Room 30 106.1F.
Corrections were made from initial pre-licensing visit conducted on 10/20/2022.
Component 3 was conducted on 10/20/2022.
Physical Plant meets requirements.

Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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