198603567-11-25-2024-28-AS-DSIS-DBSTH9-20241209134419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:06:11 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
11/22/2024 and conducted by Evaluator Daniel Konishi

COMPLAINT CONTROL NUMBER: 28-AS-20241122141838

FACILITY NAME:	CLAREMONT HACIENDA, THE		FACILITY NUMBER:	198603567
ADMINISTRATOR:	PEREZ,RICARDO LARA		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 37	DATE:	11/25/2024
		UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Ricardo Lara Perez, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff not providing food in the quantity necessary to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Initial 10-Day complaint investigation visit regarding the above allegation. LPA met with Administrator, Ricardo Lara Perez and explained the reason for the visit.

Investigation consisted of: Facility submitted a copy of the resident roster, staff roster, monthly meal schedule, and snack list. LPA interviewed Administrator, Staff #1 (S1) to Staff #5 (S5), and Resident #1 (R1) to Resident #7 (R7). LPA reviewed and obtained R1’s personnel file: Face Sheet, Physician’s Report, Physician’s Order, Meal Tracking log (November 2024), Hospice Notes, and Facility Notes. LPA observed the kitchen and have sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA also observed residents during the mealtime at lunch from 12:05pm 12:30pm.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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-20241122141838

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: 11/25/2024

NARRATIVE

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Investigation revealed the following: Allegation: Facility staff not providing food in the quantity necessary to resident. It is alleged that the facility staff are not providing enough food which has caused R1 to be severely emaciated and lost 50 pounds since being admitted to the facility. No other details are provided. During today’s visit, LPA interviewed the Administrator and five (5) out of five (5) staff and they all denied the allegation. All staff interviewed indicated that all residents at the facility receive three meals and three snacks per day. All staff interviewed also indicated that facility provides a sufficient amount of food to all of the residents in care. LPA interviewed six (6) out of seven (7) residents all claim they get enough food from the facility staff. However, LPA interviewed one (1) out of seven (7) residents that stated not liking the food provided but the resident has own food that they eat in their room. LPA observed R1 and other residents eating their meal at the dining hall during lunch time from 12:05pm to 12:30pm. LPA observed eating the following items: Orange glazed chicken, fried rice, egg roll, seasoned broccoli florets, fruit cocktails, and beverage. R1 continued to eat while being assisted by S4. R1 was in a pleasant mood while continuing to eat lunch. S3 also noted that R1 eats 3 snacks a day provided by the facility at 10:30am, 2:30pm, and 7:30pm frequently. LPA observed under record review, R1 weighted in at 104lbs based on measuring by Left Mid-Arm Circumference (LMAC) at 19cm at the date of admission which was on 07/18/2024. LPA observed the Nurse’s Notes dated 11/25/2024, S3 measured R1’s left arm at today’s visit and it measured at 20cm which has been consistent. Therefore, evidence obtained shows that R1’s weight has remained consistent from her admission date up until today’s visit. LPA observed no concerns regarding residents not getting enough food from the facility. 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 to the Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC9099 (FAS) - (06/04)

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