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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 06/15/2024
Date Signed: 06/15/2024 06:10:38 PM

Document Has Been Signed on 06/15/2024 06:10 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/
DIRECTOR:		ROBERT BARTONFACILITY TYPE:
740
ADDRESS:650 W. HARRISON AVE.TELEPHONE:
(909) 626-1227
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 360CENSUS: 100DATE:
06/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH: Minerva Naranjo (Director of Health Services)TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 6/15/2024. LPA Ramirez was greeted by Rafael Constantini (Sales and Marketing Manager) and LPA explained purpose of today’s visit. Tanya Madrid (Director of Human Services) arrived within the hour to assist with inspection.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Operational Requirements: The fire clearance is approved for (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. This facility may retain no more than (15) hospice residents. There are (11) residents under hospice care. LPA Ramirez reviewed facility liability insurance and auto registration for three (3) facility vehicles.

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.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez and staff present during inspection were unable to gain access to staff files. LPA Ramirez observed required annual training only for eight (8) out of the ten (10) staff files requested. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez was unable to review the following: CPR and First Aid, TB testing results, Health screening, fingerprint clearance, and job application. LPA Ramirez reviewed food handler certificates for kitchen staff. LPA Ramirez will issue Type B deficiency for not gaining access to staff files.

Staffing: Administrator Certificate for Robert Barton (7033961740) expires 11/02/2025.



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. The facility provides incidental medical services.

See 809-C for continuation.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2024
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: 06/15/2024
NARRATIVE
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SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/15/2024 06:10 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 06/15/2024 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT MANOR
FACILITY NUMBER: 198601672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)(1)
87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
(1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f).

This requirement is not met as evidenced by:
LPA Ramirez could not gain access to personnel records.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in residents, staff and or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2024
Plan of Correction
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Licensee will develop plan to address how this licensing agency will have access to personnel records and re-train staff on this regulation by 6/29/24. LPA Ramirez will return to review personnel records.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


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: 06/15/2024
NARRATIVE
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Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for Resident #1 (R-1) through Resident #10 (R-10). 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.

One deficiency was observed during this inspection. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
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