<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 09/05/2024
Date Signed: 09/05/2024 10:20:18 PM


Document Has Been Signed on 09/05/2024 10:20 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:
09/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Wellness Director Cassandra CrowleyTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 09/05/2024, stemming from subsequent complaint investigation conducted on 09/05/2024. LPA Ramirez was greeted by Wellness Director Cassandra Crowley and explained the purpose of the visit.

Case Management-Deficiencies findings:

LPA Ramirez received four (4) Unusual Incident/Injury Reports (LIC 624) dated 06/21/2024 & 08/06/2024. R1 has a physician’s order for Keppra (250mg) which is to be administered twice daily. On 06/21/2024, staff assisted R1 with the administration of prescribed Keppra (250mg) during PM medication pass and an additional 500mg in error. R2 has a physician’s order for Olanzapine (2.5mg) which is to be administered in the evening. On 06/21/2024, staff assisted R2 with a double dose of prescribed Olanzapine (2.5mg). R3 has a physician’s order for Lorazepam (1mg) which is to be administered as needed every 6 hours. On 08/06/2024, staff assisted R3 with the administration of prescribed Lorazepam (1mg) at 2pm, 4pm and at 9pm. R4 has a physician’s order for Lorazepam (0.5mg) which is to be administered as needed and not exceed one dose in 24 hours. On 08/06/2024, staff assisted R4 with the administration of prescribed Lorazepam (0.5mg) during the AM medication pass and again during the PM medication pass.

On 08/05/2024, the facility suspended two (2) medication technicians (S1 & S2) while an internal investigation was conducted by the facility. On 08/19/2024, S1 & S2 were terminated from their positions at the facility. Per Wellness Director Cassandra Crowley, all medications technicians have started re-training.

Based on records reviewed and interviews conducted during case management visit, staff that assisted residents with the self-administration of medication were not competent in providing the services necessary to meet the residents’ needs, which possess an immediate health and safety risk to residents in care.

One (1) type A deficiency is being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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 09/05/2024 10:20 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: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
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 assistance and care as required in Section 87608,
1
2
3
4
5
6
7
cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
8
9
10
11
12
13
14
Postural Supports. Additional staff shall be employed as necessary to perform office work, The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Staff over medicated 4 residents in June & August of 2024. Licensee will certify a plan to re-train staff on medication administration by 9/6/24. Proof of re-training must be submitted via email no later than 9/20/24.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2