<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198603567
Report Date:
10/13/2023
Date Signed:
10/13/2023 02:12:06 PM
Document Has Been Signed on
10/13/2023 02:12 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:
51
DATE:
10/13/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Donell Clark
TIME COMPLETED:
12:45 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 Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 10/10/23. LPA met with Donell Clark (Executive Director) and discussed the purpose of today’s visit.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the following domains:
Physical Plant & Environment Safety:
LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors were tested and operable. Fire extinguishers are located throughout the premises (service date of 06/13/23). Signal system was tested and operable.
Water temperature did not measure as per Title 22 regulations.
The water temperature measured as follows: jack and jill bathroom between room #10 and room #12 measured at 98.7*, in room #6 it measured at 93.5* and in room #25 measured at 110*. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.
Deficiency cited.
Health Related Services/Incidental Medical Services:
The medications are centrally stored in the medication room and in bubble packs and/or original containers.
Medications are administered as prescribed by the Physician.
Personnel Records-Training
: Staff files are maintained at the facility. LPA reviewed staff files for Executive Director (Administrator)/S-1 through Staff #5 (S-5).
Administrator Certificate for Donell Clark expired 06/30/2021. S-3 and S-4 do not have criminal clearance (civil penalties assessed). Staff training is missing for S-1 through S-5.
Deficiencies cited.
Deficiencies cited. Refer to LIC 809D. 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:
10/13/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
6
Document Has Been Signed on
10/13/2023 02:12 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:
10/13/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(f)
87405 Administrator - Qualifications and Duties (f) The administrator in facilities licensed for fifty (50) or more shall have two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (1) out of (5) staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. Per record review, current designated Administrator/S-1 appears not to have the required qualifications and duties noted on this regulation. Per S-1’s record review, S-1 has diploma and experience is in maintenance, computers, culinary and data entry.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Administrator to submit proof to reflect that Administrator meets the qualifications noted in this regulation or provide new qualified administrator with the specified qualifications noted above 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:
10/13/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
10/13/2023 02:12 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:
10/13/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on facility tour, the licensee did not comply with the section cited above as the the water temperature measured as follows: jack and jill bathroom between room #10 and room #12 measured at 98.7*, in room #6 it measured at 93.5* and in room #25 measured at 110* which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/14/2023
Plan of Correction
1
2
3
4
Administrator to measure and record water temperatures beginning today and provide proof 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:
10/13/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
10/13/2023 02:12 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:
10/13/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (2) out of (5) staff files which poses an immediate health, safety or personal rights risk to persons in care. S-3 and S-4 do not have criminal record clearance. Civil penalties assessed.
POC Due Date:
10/14/2023
Plan of Correction
1
2
3
4
Administrator to remove S-3 and S-4 from facility as S-3 and S-4 require clearance and association to be on premises.
Administrator to submit a written statement as to how Administrator will keep in compliance with this regulation 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:
10/13/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
10/13/2023 02:12 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:
10/13/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (1) out of (5) staff files which poses/posed a potential health, safety or personal rights risk to persons in care. RCFE Certificate for Donell Clark expired 06/30/2021.
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Administrator to provide a copy of the current Administrator Certficate to LPA Irra by POC due date.
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (5) out of (5) staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Training records reviewed for S-1 through S-5. Staff training records have training on dementia/sundowning (dated 07/19/23:total hours not noted), dementia/aggression (dated 07/19/23: total hours not noted), sexual expression (dated 08/07/23: total hours not noted), personal rights (dated 08/07/23: total hours not noted) and dignity and sexuality issues (dated 08/17/23; total hours: (1.00).
POC Due Date:
10/20/2023
Plan of Correction
1
2
3
4
Administrator to provide proof of staff training to LPA Irra by POC due date.
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:
10/13/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
10/13/2023 02:12 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:
10/13/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (5) out of (5) staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Training records reviewed for S-1 through S-5. Staff training records have training on dementia/sundowning (dated 07/19/23:total hours not noted), dementia/aggression (dated 07/19/23: total hours not noted), sexual expression (dated 08/07/23: total hours not noted), personal rights (dated 08/07/23: total hours not noted) and dignity and sexuality issues (dated 08/17/23; total hours: (1.00).
POC Due Date:
10/27/2023
Plan of Correction
1
2
3
4
Administrator to provide proof of staff training as noted on this regulation to LPA Irra by POC due date.
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:
10/13/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/13/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6