198603567-9-12-2024-28-AS-TVAO-D9EMVW-20240924095723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:52:44 PM

Substantiated

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
08/12/2024 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240812152831

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: 46	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cassandra Crowley, Wellness Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent residents from engaging in a physical altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit for the allegation listed above. LPA arrived unannounced and met with Wellness Director, Cassandra Crowley. The purpose of the visit was explained.

On 8/16/24, LPA Chan conducted the initial visit to gather documents such as the resident and staff rosters and for Resident #1 (R1). LPA also toured the facility and interviewed 6 staff and 2 residents. During the visit today, LPA held additional interviews with 3 staff and 2 residents.

The investigation revealed the following:
Allegation – Staff did not prevent residents from engaging in a physical altercation. It is alleged that Resident #1 (R1) physically assaulted Resident #2 on 5/17/24. LPA interviewed a total of 9 Staff. Staff on duty and incident report on 5/17/24, indicated that they observed R1 pacing up and down the hallway.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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-20240812152831

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: 09/12/2024

NARRATIVE

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R1 later went into R2’s room and heard R2 screaming. Staff immediately went to check on the situation. Staff stated R2 sustained red marks to the arms and face.

7 out of the 9 Staff acknowledged that R1 had been aggressive while residing at the facility. Some staff reported they had been assaulted by R1 and seen R1 hit or push other resident at times. Staff indicated the behaviors had been reported to management when it occurred and felt R1 needed a higher level of care. One of the staff stated that R1’s medications had been changed/adjusted several times due to the aggressive behaviors. Upon review of R1’s medication logs, it appeared that R1 was not consistent in taking medications and was documented when R1 refused them. Additionally, LPA reviewed R1’s file and the facility notes showed that R1 had displayed physical aggression towards staff and/or residents at least 8 different times since being admitted on 2/9/22. There was no updated care plan to address the aggressive behaviors. LPA attempted to interview additional residents, but due to their cognitive ability, the information provided could not corroborate this allegation. According to information gathered, Staff were aware of R1’s aggressive behaviors, however, adequate supervision was not provided to closely monitor R1.

Based on staff interviews and file review, 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 being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the Wellness Director. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240812152831

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/13/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall provide the procedures to address residents who display aggressive behaviors at the facility. The plan shall be submitted to LPA by 9/13/24.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure that staff prevented R1 from assaulting another resident which poses an immediate health and safety risks to others in care.	8 9 10 11 12 13 14
	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 Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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