198603567-9-17-2024-28-AS-RORN-D99QJ3-20240919121205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:11:54 PM

Substantiated

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
07/09/2024 and conducted by Evaluator Sanjay Vaid

COMPLAINT CONTROL NUMBER: 28-AS-20240709110052

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: 45	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Dennis Downey, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility did not ensure that resident received their prescribed medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit regarding the above allegation. LPA conducted the initial complaint visit on 07/15/24. During today’s visit LPA met with Administrator Denise Downey and explained the purpose of the visit.

The investigation consisted of the following: LPA Vaid obtained staff and resident roster and reviewed four (4) resident files, five (5) med-tech files, Medication Administrator Records (MARs), face sheet for R1, and physicians report from the facility. LPA toured the facility with Wellness Director Cassandra Crowley. LPA Vaid interviewed five (5) staff #1-5 (S1-S5) and six (6) residents (R#1-R#6).

The investigation revealed the following: Regarding allegation Facility did not ensure that resident received prescribed medications. It is alleged that the staff did not give medications to residents as prescribed.

Continued on 9099 C..........

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 4

Control Number 28-AS-20240709110052

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: 09/17/2024

NARRATIVE

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LPA interviewed 5 (five) staff and 4 out of 5 staff acknowledged the above allegation, 4 of the 5 staff were med-techs and they stated that their medication process is very thorough and leave little to no room for errors, since the medication is securely stored and labeled very clear. R1 was not given medications as prescribed due to insurance issues, pharmacy was not able to process the medication ordered. The med-techs interviewed stated that they had notified the lead nurse on duty during the period starting in April 2024. According to R1’s social worker, R1 had been approved for Medicare part B plan to cover the cost of their medications, since April of 2024. The administration staff (during that period) failed to forward the Medicare B plan information to the pharmacy. According to the physicians’ report dated 05/02/2023, R1 needs assistance with organizing and administering and ordering their medications. LPA interviewed 6 (six) residents and 6 out of 6 residents could not corroborate the above allegation. When medication is low and running out, the med-tech on duty ensures the medication is refilled by either contacting the pharmacy, physician or the POA (person of authorization) usually a family member. None of this occurred, leading to the fact that R1 had been without five (5) medications for 2 ½ months (two and half months).

On 07/08/2024, in house service coordinator from Scan Brace health agency visited the facility and noticed R1’s condition and did an assessment on R1. Service coordinator immediately contacted the pharmacy and ordered all the medications R1 needed. The pharmacy filled the order and delivered it the next day. The facility persons in-charge of contacting and forwarding the insurance information to the correct parties failed to deliver Medicare plan B authorization to the pharmacy billing department. Facility did not provide or seek out to provide necessary assistance for R1’s to get medication.

The medications not prescribed to R1, as indicated on the MAR’s(Medication Administered Record) for 04/14/2024 to 07/09/2024 are as follows:
OMEPRAZOLE, 20MG
PRAVASTATIN, 80MG
TAMSULOSIN, 0.4MG
TRIAMTERENE- HYDROCHILOROTHIAZID, 25MG
VITAMIN D-3, 25MCG

Continued on 9099 C...........

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20240709110052

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/17/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-	1 2 3 4 5 6 7	Administrator will give med-techs and facility staff in-charge of administering medications, including: monitoring, ordering and administering, training for residents personal rights by due date 09/25/2024.
	8 9 10 11 12 13 14	administered medications as needed. The facility staff not contacting or communicating insurance update to the pharmacy billing department for R1’s Medicare part B, so that the resident could receive their medication on a consistent basis. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 28-AS-20240709110052

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: 09/17/2024

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 26 27 28 29 30 31 32	Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8. Are cited on the attached LIC 9099D. An exit interview was held, and a copy of this report and appeal rights were provided to Administrator, Denise Downey.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4