198603567-10-10-2023-28-AS-EIRA-CWGS6V-20231010133635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:50:46 PM

Document Has Been Signed on 10/10/2023 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 50	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Donell Clark		TIME COMPLETED:	03:00 PM

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	Licensing Program Analysts (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Donnel Clark (Executive Director/Administrator) and discussed the purpose of today’s visit. This facility consists of one large building with Wings A, B, C and D, bathrooms, kitchen, dining area, activity room, medication room, and indoor/outdoor activity areas. This facility is licensed to serve (68) non-ambulatory residents, of which, (40) may be bedridden and (12) may be on hospice. Bedridden designated rooms are 2-6, 9-20 and 22-26. Per Mr. Clark, there are no bedridden residents, (8) residents on hospice and (8) residents receiving home health agency services at this time. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (68) non-ambulatory residents, of which, (40) may be bedridden and (12) may be on hospice. Bedridden designated rooms are 2-6, 9-20 and 22-26. Staff are adhering to operational requirements. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Executive Director/S-1 through Staff #5 (S-5). Staff have their Health Screening and Tuberculosis Screening on file. S-2 last CPR certificate expired 12/2021, S-3 (med-tech) and S-4 (caregiver) did not have CPR certificate in file, and S-5 CPR certificate expired 01/2022. Deficiency cited. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/10/2023

NARRATIVE

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Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed. Note: Facility Administrator to ensure that admission agreements and all required documents for all residents are under the new ownership name (Claremont Hacienda). R-1, R-4 and R-5 have admission agreements and other required forms in file under the previous facility name (Oak Park). This Information was provided to Donell Clark.

Resident Rights-Information: Resident rights are included in Resident files. However, the let-us-no poster was observed to be posted inside the staff break room and is 8x10 in size. Deficiency cited.

Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items.. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating. Posted menu observed.

Disaster Preparedness: The facility has the Emergency Disaster Plan in place.

The following domains remain pending:

Physical Plant
Health Related/Incidentals
Personnel Records

Deficiencies cited. Refer to LIC 809D. LPA may issue further citations.

Exit interview conducted, copy of appeal rights and a copy of this report provided to Donell Clark.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation/record review, the licensee failed to comply in the section above in that the LPA observed S-2 last CPR certificate expired 12/2021, S-3 (med-tech) and S-4 (caregiver) did not have CPR certificate in file, and S-5 CPR certificate expired 01/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Administrator shall submit proof of enrollment for this training to LPA Irra by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee failed to comply in the section above in that LPA observed the CCL "Let us no" complaint poster posted. However, the poster measured 8" x10" as opposed to the required measurement of 20" x 26" as per Title 22; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Administrator shall submit proof to LPA Irra that a 20 x 26 complaint poster has been posted.

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: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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