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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:01:22 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
03/14/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230314115533
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:
03/21/2023
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Executive Director, Donell ClarkTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident was hit with an object by an unknown person in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Donell Clark, Executive Director and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed files for random residents and Resident #1 (R1) and obtained copies from Resident #1 (R1) file such as Physician's Report, Identification and Emergency Information Sheet, Preplacement Appraisal and Appraisal, Unusual Incident/Injury Reports (3/13/2023) and Medication Administration Records/MARs (Jan 2023-Mar 2023). LPA also interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #2 (R2) - Resident #6 (R6). At 3:35pm, LPA interviewed Resident #1 (R1) telephonically as he is now residing in another facility.

The investigation revealed the following: in regard to the allegation "Resident was hit with an object by an unknown person in the facility." It is alleged that a resident was hit by an object while in care. Resident did not know if this was done to him by another resident or staff. *****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
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 5
Control Number 28-AS-20230314115533
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: 03/21/2023
NARRATIVE
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Interviews conducted with staff members indicated they did not witness the alleged incident. Staff members interviewed indicated they have never hit any of the residents. S3 stated that R1 hit his forehead and grated his forehead on the wall and had minor abrasions when he was trying to grab his bag. S3 stated that a housekeeper witnessed it. S2 received and submitted an incident report to CCLD regarding the incident on 3/13/2023. S1-S3 indicated that due to his cognitive impairment, he likes making false accusations and would call 911 or Fire Department many times to complain. Interviews conducted with residents indicated they did not witness the alleged incident. Residents interviewed indicated they have never been hit by any staff member or other residents. Additionally, R3 who is R1's roommate stated that he never saw any staff or other resident hit R1 and could not identify possible perpetrator/s. There were no witnesses, camera footage, or evidence obtained during the investigation to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the Executive Director, Donell Clark along with the Appeals Rights.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/14/2023 and conducted by Evaluator Bennette Pena
COMPLAINT CONTROL NUMBER: 28-AS-20230314115533

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:
03/21/2023
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Executive Director, Donell ClarkTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff prohibited resident from calling the police by confiscating their phone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Donell Clark, Executive Director and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed files for random residents and Resident #1 (R1) and obtained copies from Resident #1 (R1) file such as Physician's Report, Identification and Emergency Information Sheet, Preplacement Appraisal and Appraisal, Unusual Incident/Injury Reports (3/13/2023) and Medication Administration Records/MARs (Jan 2023-Mar 2023). LPA also interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #2 (R2) - Resident #6 (R6). At 3:35pm, LPA interviewed Resident #1 (R1) telephonically as he is now residing in another facility.

The investigation revealed the following: in regard to the allegation "Staff prohibited resident from calling the police by confiscating their phone ." It is alleged that the staff took the resident's cell phone away because he wanted to call the police. *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230314115533
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: 03/21/2023
NARRATIVE
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Interview with S1 revealed that R1's cell phone was taken away from him by the staff at the facility after R1 called the Hospital to complain and make false accusations. S1-S3 confirmed that R1's cell phone likes making false allegations and kept calling 911, fire department and even hospitals to complain. S1 stated that R1's cell phone was taken away from him on Sat., 3/11/2023 to stop R1 from continuously calling different agencies to make false allegations. Additionally, S1 stated that R1's cell phone was given back to R1's family member after R1 left the facility on Sun., 3/12/2023. S1's statement was corroborated by S2 and S3. S2-S3 confirmed that R1's cell phone had to be taken away from R1 to prevent him from calling 911 and make false accusations. Interviews conducted with residents indicated that they have not seen or heard a resident's cell phone being confiscated. R2 has a cell phone and stated that his cell phone was never taken away from him by anyone.

Based on LPA’s observations, interviews, and record reviews, 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, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Executive Director, Donell Clark along with the Appeals Rights.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230314115533
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: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2023
Section Cited
CCR
87468.1(a)(12)
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87468.1 Personal Rights of Residents in All Facilities...(a) Residents .. for the elderly shall have..personal rights: (12) to keep and use their own personal possessions..
This requirement is not met as evidenced by:
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Administrator will ensure residents personal rights are in place at all times, will re-train staff on Resident's Personal Rights and will update admission agreement plan of operation regarding cell phones and submit proof of training and agenda to CCLD by POC due date.
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Based on interviews, and document review conducted, the Administrator did not allow resident to keep and use his own cell phone which was his personal possession which poses potential risk to health, safety, or personal rights to residents in care.
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5