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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:09:33 PM

Document Has Been Signed on 08/18/2023 04:09 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 MANORFACILITY NUMBER:
198601672
ADMINISTRATOR:GREG HIRSTFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 360CENSUS: 210DATE:
08/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Robert BartonTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 07/27/23. LPA met with Robert Barton (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:

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Robert Barton expires 01/31/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff #7 (S-7). Pertinent staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training.

Resident Rights-Information: Resident rights are posted and included in Resident files. Let-Us-No poster posted. LTCO poster posted.

Resident Rights-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #8 (R-8). 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, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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 MANOR
FACILITY NUMBER: 198601672
VISIT DATE: 08/18/2023
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Physical Plant & Environment Safety: The kitchen, dining area, Summer House (Dementia) and The Lodge (Assisted Living) locations were amongst the toured locations. Smoke alarms and carbon monoxide detectors were observed throughout the tour. Fire extinguishers are located throughout the premises (service date of 04/22/23). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars. The swimming pool is gated and locked.

Planned Activities: Staff provide a variety of activities for the residents. Activity calendar posted. There is a full-time Life Enrichment Director and Life Enrichment Assistants focusing on planned activities only.

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 room has adequate seating. Posted menu observed. Emergency water supply observed.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services.

No deficiencies. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Robert Barton.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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