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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601672
Report Date: 03/18/2025
Date Signed: 03/18/2025 04:19:17 PM

Document Has Been Signed on 03/18/2025 04:19 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: 234DATE:
03/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:52 PM
MET WITH:Tanya Madrid-Director of Resident ServicesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Incident on 03/18/2025, stemming from incident report received on 2/11/2025. LPA was greeted by Administrator Robert Barton, Director of Health Services-Minerva Naranjo, Director of Resident Services-Tanya Madrid and explained the purpose of the visit.

Case Management-Incident findings:

On 2/11/25, LPA Ramirez received an Unusual Incident Report (LIC 624) indicating the immediate closure of the facility kitchen by the Los Angeles County Department of Public Health (DPH) on 2/11/2025. The facility kitchen was closed due to cockroach infestation. Facility kitchen remained closed from 2/11/25 through 2/15/25, for repairs and extermination of roaches. Facility staff provided meals to residents that came from a local facility. All meals were individually boxed and in disposable containers. On 2/15/2025, the DPH returned and conducted another re-inspection. The DPH found the facility eliminated the cockroach infestation and the facility public health permit was reinstated.



On 3/18/25, LPA Ramirez conducted a tour of facility kitchen and observed repairs made to kitchen walls. Interview with Administrator Barton revealed the facility changed pest control company and has an updated pest elimination service contract. LPA Ramirez obtained copies of ECOLAB pest elimination services agreement, DPH official inspection reports, and facility kitchen staff re-training.

Based on records reviewed and interviews conducted, LPA Ramirez will issue one (1) type A deficiency for violation of Title 22, Division 6, Chapter 8, Article 10. Food Services- 87555(b)(27) General Food Service Requirements- (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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Document Has Been Signed on 03/18/2025 04:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/18/2025 at 04:03 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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2025
Section Cited
CCR
87555(b)(27)

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General Food Service Requirements- (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.This requirement was not met as evidenced by:
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Licensee made kitchen repairs, conducted kitchen staff retraining and updated their pest control services. *NO FURTHER ACTION IS REQUIRED*
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On 2/11/25, facility kitchen was closed down for 5 days due to roach infestation.
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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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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