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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:44:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/08/2023 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230208120008
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: 48DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Cassandra Crawley Wellness Director TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Questionable Death.
Staff are not administering medications according to doctors orders.
Staff do not ensure that resident needs are met.
Facility roof is in disrepair.
Facility has mold.
Staff did not adequately care for resident's wound.
Staff did not ensure that resident's were adequately fed.
Staff did not keep the facility clean & sanitary.
INVESTIGATION FINDINGS:
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***The licensing report created on 04/18/24 is being superseded by this licensing report dated 08/08/24. The licensing report is being redelivered due to additional interviews that were conducted and further information was obtained.The investigation findings will remain the same.***

On today's visit 8/8/24,Licensing Program Analyst (LPA) Tyler Reyes made an unannounced subsequent visit to the facility for the purpose of continuing the investigation and redelivering findings. LPA Reyes met with Wellness Director, Cassandra Crawley, and explained the reason for the visit and obtained a copy of the resident and staff roster.
During todays visit 8/8/24, LPA Reyes interviewed resident #5 (R5), R10, and R11. LPA Reyes interviewed R1's and R2's responsible party on 8/7/24. LPA Reyes toured the physical plant. Cleaning service was observed performing housekeeping tasks in R5's room. The facility grounds were found to be in good repair.Staff were observed tending to residents' needs, providing care and assistance as required. LPA Reyes observed food supplies and medication room.
(Report continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
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 5
Control Number 28-AS-20230208120008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
VISIT DATE: 08/08/2024
NARRATIVE
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On 04/18/24, LPA Maldonado conducted a follow up visit and obtained a copy of the resident and staff roster and conducted a tour of the physical plant with Denise with special focus on food supplies, linens, and personal care and hygiene supplies. Copies of roofing contract agreement, dated: 2/09/24 and 8/07/23, and a work order/assessment for mold dated: 2/06/24, were also obtained. LPA Maldonado
reviewed (3) resident medications and obtained Medication Administration Records (MARs) for Residents#1-5 (R1-R5). Interviews were also conducted with Staff#3-10 (S3-S7) and R3-R5. LPA Maldonado was unable to interview Residents#1-2 (R1-R2) due to residents deceased.

On 02/09/23, LPA Maldonado made an initial visit, which consisted of the following: conducted a tour of the physical plant with staff, Amber conducted interviews with Staff# 1-2 (S1-S2). LPA also obtained a copy of the resident and staff roster and the following documents for Residents# 1-9 (R1-R9): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, Hospice Care Plan/Wound Care Plan, Death Reports, and Incident Reports for the months of December 2022 - February 2023.

The investigation revealed the following:

Regarding allegation: Questionable Death.
It is alleged that staff did not check on R1 routinely due to R1 being bedbound, and was later found deceased by staff, which resulted in the paramedics filing a police report as they found R1 to have been deceased for some time prior to being called. Per staff interviews, (7) of (7) staff denied the R1's death being suspicious or questionable. Staff also denied not checking on R1 routinely. Staff conduct routine/status checks on all residents every (2) hours and as needed. Per S1, S2, and R1's hospice records, R1 was on hospice at the time of R1's death. Per Death Report dated: 12/08/22, R1 passed on 12/07/23 in the morning and was accompanied by R1's family at their bedside. Hospice was notified of R1's passing. S1 and S2 denied the paramedics contacting the police to file a police report due to R1's passing. (6) of (6) residents interviewed could not corroborate the allegation. On 8/7/24 an in conducted an interview


(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230208120008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
VISIT DATE: 08/08/2024
NARRATIVE
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Regarding allegation: Staff are not administering medications according to doctors orders.
It is alleged that staff are instructed to give residents more medication than prescribed, to keep residents form being too active, and staff are not documenting this. Per staff interviews, (4) of (7) staff denied the allegation. Per S1 and S3, all medication is accounted for and documented at the change of every shift. If additional doses are administered and not documented, it would be easy to detect. Per S1, over-medicating residents would have warranted immediate termination and it would have been reported. Per resident interviews, (6) of (6) residents could not corroborate the allegation due to cognitive impairment. LPA reviewed (3) resident medications and observed them to be documented properly and given as prescribed.

Regarding allegation: Staff do not ensure that resident needs are met.
It is alleged that staff do not shower residents, change their adult briefs, provide clean linens, or change their clothing as needed, including changing residents into pajamas from their day clothes when putting them to bed. Per staff interviews, (7) of (7) staff denied the allegation. Staff stated to be aware of residents needs and are checked every (2) hours for incontinence needs. Residents are changed out of their clothing as needed if there experience accidents, and are changed in the morning and at night as appropriate. LPA observed a sufficient amount of incontinence supplies, hygiene supplies, linens, and clothing for residents in care.
On 4/18/24, LPA also observed residents for any signs of neglect and noted that residents were all wearing clean and appropriate clothing, were well groomed, free from odors, and were observed to be comfortable while sitting/laying, engaging in different activities.

Regarding allegation: Facility roof is in disrepair.
It is alleged that the facility roof is leaking in resident room# 18, where water is falling directly on a resident's head, and is leaking in the lobby affecting the light fixture above the reception desk. On 4/18/24 LPA observed the light fixture near the reception desk to be working properly and there were no signs of a leak. However, upon driving up to the facility, LPA Maldonado observed tarps covering the outside of the roof on one side of the building. Per S1, some rooms and part of the laundry room were affected by the weather and are currently being repaired. LPA Maldonado inspected resident rooms#11, 14, 17, 18, 19, and 22 and observed rooms#11, 19, and the laundry room to be under repair. The laundry room is operable and parts of the drywall were removed for repairs, but is secured. Residents that were occupying rooms#11-19 were relocated during the repairs. LPA observed the rooms to have drywall removed and wooden frame were exposed, however the room doors are maintained closed during repairs. The roofing contract agreement, dated: 2/09/24 and 8/07/23 reflect the work contracted for and is currently under repair. (6) of (6) residents interviewed could not corroborate the allegation.

(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230208120008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
VISIT DATE: 08/08/2024
NARRATIVE
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Regarding allegation: Facility has mold.
It is alleged that due to there is mold growing in room#18 due to the leaks it was experiencing. Per LPA's observations on 4/18/24, no mold was seen/discovered in the inspected resident rooms# 11, 14, 17, 18, 19, and 22. The work order/assessment for mold dated: 2/06/24 was obtained and did not mention mold found in the rooms where repairs are occurring. Per staff interviews, (7) of (7) staff denied the allegation and stated there is no mold in the building. (6) of (6) residents interviewed could not corroborate the allegation.

Regarding allegation: Staff did not adequately care for resident's wound.
It is alleged that R2 was admitted to the facility with a hip wound and staff were not providing proper care for the wound. Per facility Nurse Admission Record, it was documented that on 10/11/22, R2 was admitted with a healing wound on the left and right side of the hip. On 10/22/22, the facility faxed a notice to R2's physician to notify of that the found on the left hip was open and necrotic. R2's physician responded with an order for home health services. Per fax communication with R2's physician on 10/31/22, R2 was found to continue to scratch wound and wound had reopened. R2's physician recommended facility continue to monitor resident. Per Hospice records, R2 was admitted to hospice on 11/18/22 for routine level of care and wound care. Per S1, R2's wounds started healing after R2 was admitted to hospice as R2 was receiving daily care for the wounds. (4) of (7) staff interviewed stated that residents with wounds receive regular care from hospice or home health and staff observe residents and report any changes. (6) of (6) residents interviewed could not corroborate the allegation.

Regarding allegation: Staff did not ensure that resident's were adequately fed.
It is alleged that there are times when the facility water jugs were empty and staff did not leave snacks out for caregivers to give to residents during the night time, which made caregivers feel the need to give residents their own water and snacks. Per staff interviews, (7) of (7) staff denied the allegation. S7 states that residents receive 3 balanced meals per day and include snacks throughout the day as requested. On 4/18/24, LPA observed the facility food supplied and observed a sufficient amount of perishables and non-perishables available for residents in care. The food available included, but was not limited to fresh fruit, vegetables, meats, juices, sodas, cookies, cereals, yogurt, Jell-o. LPA Maldonado also observed water carafes readily available at different stations of the facility for resident use. All staff have access to refill the water at any time. (6) of (6) residents denied the allegation. They stated staff feed them at every meal time, they receive snacks when they want, and can get water whenever they want or need it.

(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230208120008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT HACIENDA, THE
FACILITY NUMBER: 198603567
VISIT DATE: 08/08/2024
NARRATIVE
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Regarding allegation: Staff did not keep the facility clean & sanitary.
It is alleged that resident's bed linens are dirty, residents are not changed often, the roof is leaking, and there is mold at the facility. Per staff interviews (7) of (7) staff denied the allegation. They stated that there is a housekeeper at the facility (7) days a week. S5 states they are responsible for all laundry needs for the residents which includes their clothes, bedding linens, towels, and anything else they may need. S6 states to come in (5) times per week to clean the facility. This includes taking out the trash, sweeping, mopping, dusting, changing bed linens, and anything else that is needed. S3 and S4 also stated that as caregivers and med-techs, they also assist with facility clean-up and disinfection as needed. Per resident interviews, (6) of (6) During the 04/18/24 visit, LPA Maldonado observed S6 taking out the trash in several rooms and sweeping the floor. LPA inspected client rooms and bathrooms and observed them to be clean, sanitary, and free of odors.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.


LPA Reyes to deliver report because additional information was obtained.The findings will remain the same and no deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5