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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 09/05/2024
Date Signed: 09/05/2024 10:13:20 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
08/05/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240805095328
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
UNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Wellness Director Cassandra CrowleyTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff yell at residents.
Facility staff are not providing residents with activities.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 09/05/2024 regarding the above allegations. LPA Ramirez conducted initial complaint investigation visit on 08/05/2024 and a needs further investigation was required. LPA Ramirez was greeted by Wellness Director Cassandra Crowley and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 6 interviews (S1 – S6), Resident#1-5 (R1-R5) interviews, copies of Resident#1 (R1) Physician’s Report, R2-R5 Identification and Emergency Information, and physical plant tour.

See 9099-C for findings.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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Control Number 28-AS-20240805095328
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: 09/05/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegations: Facility staff yell at residents - It is alleged that S4 yells at residents in care to “STOP!” when residents do something S4 does not like. Six (6) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. During facility tour, LPA Ramirez observed several caregivers providing care and supervision in the facility dining room and activities room. During records review, LPA Ramirez did not observe documentation to suggest S4 was reprimanded for yelling at residents. 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.

Facility staff are not providing residents with activities- It is alleged S1 does not plan activities with residents on a regular basis. Six (6) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. During tour, LPA Ramirez observed several residents in the Activities/Tv room, seated, while throwing a large ballon back and forth to each other. LPA Ramirez observed several magazines, scrapbooking pages and coloring books on nearby tables. LPA Ramirez observed a facility activities calendar posted in the facility activities/TV room. During records review, LPA Ramirez observed S1’s personnel record and it revealed S1’s full-time responsibility is to organize, conduct and evaluate planned activities. LPA Ramirez observed S1 has more than 1 year experience conducting group activities, knowledgeable in evaluating residents needs, and supervising other employees and in training volunteers. 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 deficiencies were cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
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