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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603567
Report Date: 11/13/2023
Date Signed: 11/13/2023 10:56:49 AM


Document Has Been Signed on 11/13/2023 10:56 AM - 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, THEFACILITY NUMBER:
198603567
ADMINISTRATOR:CLARK, DONELLFACILITY TYPE:
740
ADDRESS:501 SOUTH COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 51DATE:
11/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Donell ClarkTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPAs) Elizabeth Irra conducted a Case Management POC visit. LPA met with Donell Clark and discussed the purpose of today’s visit. On 10/13/23 LPA Irra conducted a subsequent annual inspection visit in which citations were issued. On 10/27/23, LPA Irra conducted a Case Management POC visit and issued Civil Penalties from 10/21/23 through 10/26/23.

During the 10/13/23 visit, LPA issued the following citation: 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: 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). Plan of Correction (due 10/20/23): Administrator to provide proof of staff training to LPA Irra by POC due date. As of today, this remains pending. Civil Penalties assessed from 10/27/23 through 11/12/23. **Refer to LIC 809C for the continuation of this report**

Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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: 11/13/2023
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During the 10/13/23 visit, LPA issued the following citation: 87405(f) 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. 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. Plan of Correction (due 10/20/23): 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. As of today, this remains pending. Civil Penalties assessed from 10/27/23 through 11/12/23.

Civil Penalties assessed during today's visit. Refer to LIC 421FC forms. Civil Penalties will continue to be assessed until the corrections have been made.

Exit interview conducted, LIC 421FC/Civil Penalties forms, appeal rights and a copy of this report were provided to Donell Clark.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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