The Claremont Hacienda

Allegation investigated: Staff hit resident causing injury.

Licensing Program Analyst (LPA) Daniel Konishi mailed a copy of this report to the former licensee's last known mailing address via USPS certified mail to communicate the findings related to the above-mentioned allegations. The facility has been closed since 05/23/2025. On 03/13/2025, the initial investigation visit was conducted. The investigation consisted of the following: Investigation consisted of the following: LPA requested a copy of staff and client rosters. LPA conducted a tour of facility and common areas with the Administrator. LPA also requested copies from Resident #1 (R1’s) file such as: Identification and Emergency Information, Admission Agreement, Admission Record, Physician's Report, Special Incident Reports. The Administrator will send Appraisal Needs and Services Plan and Pre-Placement Appraisal to the LPA. Substantiated LPA also requested copies of the Staff #1 (S1) and Staff #2 (S2) file such as: Code of Conduct, Receipt of Acknowledgement of Employee Handbook, Criminal Background Clearance, Employee Warning Document, BLS training, On-the-Job Orientation Training, and Position Description. LPA interviewed R1 and the Administrator during the visit. On 05/15/2025, LPA interviewed Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), and the Administrator over the phone. On 06/20/2025, LPA interviewed R1’s family member and obtained a photograph of R1’s injuries taken after the incident. The investigation revealed the following: in regards to the allegation: “Staff hit resident causing injury.” It is alleged that on 3/10/2025, at 5am, R1 was struck in the face by S1 resulting in a black eye when staff were attempting to change R1. Shortly after the incident, Claremont Police were called, and they arrived at the facility on 3/10/2025. LPA interviewed R1 and R1 indicated that they were “picking” at their eye because it was itchy and could not recall being hit by S1 or any other staff. LPA interviewed S1 and S1 denied the allegations stating that S1 did not hit or strike R1 in the face and S1 was unsure of how R1 had obtained the black right eye. LPA interviewed the Administrator and the Administrator stated that S1 was initially suspended pending an investigation, however at the conclusion of their internal investigation S1 was terminated because management felt reasonable suspicions that S1 had in fact struck R1 in the face. LPA interviewed S2 and S2 corroborated with the allegation stating that S2 witnessed S1 striking R1 on the face during the 03/10/2025 incident. S2 indicated that they were present during the interaction and S1 aggressively slapped R1 in the face when R1 was being combative with staff as they were attempting to change R1. LPA interview S3 and although S3 did not directly witness the incident, S3 corroborated the allegation by confirming that R1 had an injury near their right eye the day of the alleged incident. LPA obtained a copy of the police report from the Claremont Police Department that indicated that law enforcement responded to the facility to investigate the incident and the police officer observed redness and bruising around R1’s right eye. LPA also reviewed picture that was provided regarding R1’s injury and the picture shows redness around R1’s eye area. Based on staff and resident interviews, record review, there was sufficient evidence to corroborate with the allegations. Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D. An immediate $ 500.00 Civil Penalty is being issued as a result of staff causing injury to resident in care. Copy of this report and appeal rights will be mailed to the licensee’s last known mailing address via USPS certified mail as the facility closed effective 05/23/2025.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 28-AS-20250311170813

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 6, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interviews and record review, obtained, Administrator failed to ensure the safety of Resident #1 (R1) from suffered a eye injury from Staff #1 (S1) hitting R1 while in care. This poses a immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Administrator/Licensee to ensure that each resident has personal rights. Administrator/Licensee is to ensure that all residents are free from corporal or unusual punishment at all times.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Other on 05/23/2025, due to the pending closure of facility on 5/21/2025. LPA was greeted by Erika Montoya-Assistant Administrator and explained the purpose of the visit. LPA conducted a physical plant inspection to verify the facility no longer houses residents. LPA Ramirez did not observe residents in the facility. All residents have been relocated. Per Assistant Administrator- Erika Montoya, no direct care staff will be working at the facility. Assistant Administrators Erika Montoya agreed to mail original facility license to LPA Ramirez by 05/30/2025. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided email.the state’s words, verbatim · CDSS document, May 23, 2025

Allegation investigated: Staff did not address a change in resident's health condition Staff did not address resident's scabies infection Staff chemically restrained resident

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Montoya and explained the purpose of today's visit, shortly after Administrator Ricardo Lara-Perez arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of the following documents within Resident #1's (R1) file: Admission Agreement, Physician Report, Court Document, Charting notes from 1/2025-3/2025, Hospital Discharge Paperwork - dated 3/16/25, ALW Assessment - dated 12/23/2, Medication List; and interviewed Staff (S1-S4). Faclity is undergoing closure and there are currently 0 residents admitted in the facility, therefore, there were no resident interviews conducted. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not address a change in resident's health condition It is alleged that staff did not address R1’s health because the resident’s conservator refused treatment. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that they do not refuse residents at the facility treatment when needed, additionally staff stated that R1’s conservator has never instructed staff to refuse treatment for R1. LPA reviewed Assisted Living Waiver assessment for R1 dated 12/2024 and there were no notations or observations made stating that R1 had a change of condition, these assessments are done every 6 months and this assessment was the most recent. LPA reviewed hospital discharge paperwork dated 3/16/24 and resident was sent back to facility with no new medications or orders. LPA reviewed R1’s charting notes and there weren’t any notes indicating resident had a change of condition (notes of hospitalization was listed on charting notes). Allegation: Staff did not address resident's scabies infection It is alleged that staff did not seek treatment for R1 as the resident’s conservator refused treatment. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, each stated that there had not been any residents with scabies and R1 did not have any questionable skin marks to assume R1 had scabies. LPA reviewed R1’s file and there was nothing documented within file that stated resident had scabies. Allegation: Staff chemically restrained resident It is alleged that staff were over-medicating R1 leaving resident drowsy and sleepy. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that R1 had very little medications prescribed and MedTech’s administered medication to R1 per the doctors order. S1 and S2 stated that medication that R1 would take did have side effects that would make the resident sleepy therefore these medications were given to resident at bedtime. LPA reviewed R1’s medication list and observed 2 medications that were prescribed by physicians, side effects listed did include drowsiness. There were no resident interviews done during visit as facility is closing and all residents have been transferred to different facilities, additionally, R1 was not available for interview. Based on statements and interviews conducted, review of resident file and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 28-AS-20250520115719

Allegation investigated: Staff did not safeguard resident's personal items

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Montoya and explained the purpose of today's visit, shortly after Administrator Ricardo Lara-Perez arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of the following documents within Resident #1's (R1) file: Admission Agreement, Physician Report, Court Document, Charting notes from 1/2025-3/2025, Hospital Discharge Paperwork - dated 3/16/25, ALW Assessment - dated 12/23/2, Medication List; and interviewed Staff (S1-S4). Faclity is undergoing closure and there are currently 0 residents admitted in the facility, therefore, there were no resident interviews conducted. (Continued on LIC9099-C) Substantiated The investigation revealed the following: Allegation: Staff did not safeguard resident's personal items It is alleged that when R1’s personal items were picked up (as resident was relocated to another facility) most of R1’s clothing was missing. LPA interviewed 4 staff and 4 out of 4 staff stated they did not complete a inventory sheet upon discharge. S2 and S3 stated all items were boxed and sent with resident to new placement upon discharge and no items were left behind. LPA reviewed admission agreement and per admission agreement a personal property inventory is established upon admission and a receipt is to be signed upon discharge. LPA reviewed R1s file and there was no record of the inventory list nor the inventory receipt. There were no resident interviews done during visit as facility is closing and all residents have been transferred to different facilities, additionally, R1 was not available for interview. Based on LPAs observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 28-AS-20250520115719

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(1) · Plan of correction due date: May 29, 2025

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met as evidence by: During interviews 4 staff stated that the personal property inventory was not completed, during file review there was no copy of R1's personal property inventory. Interview with S2 it was expalined that staff were not completing the personal property inventory list.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee/Administrator to review regulation and submit a competed and signed LIC9098 Proof of Correction form to LPA by POC due date. This signed LIC9098 is an agreement stating the regulation has been reviewed, understood, and followed moving foward. tena.herrera@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabriela Castro conducted an unannounced Case Management Visit-Other on 05/20/2025, due to the pending closure of facility on 5/21/2025. LPA's were greeted by Administrator Ricardo Lara-Perez and LPA explained the purpose of the visit. LPA's conducted a physical plant inspection and inspected food supply. Facility staff were observed providing care and supervision. Administrator Lara-Perez revealed Long Term Care Ombudsman (LTCO) has been assisting the facility with relocation of some residents. Administrator Lara-Perez revealed caregivers are on 12hr shifts. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff did not accept resident back into care following hospitalization.

*A subsequent visit was conducted on 5/09/25 and the purpose of the visit was to change the findings from substantiated to unsubstantiated. This report supersedes the previous report dated 3/13/25 and 4/26/25.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/13/2025 regarding the above allegation, to deliver findings. LPA Ramirez conducted initial complaint investigation on 02/07/2025 and a need further was documented. LPA was greeted by Administrator Ricardo Lara Perez and explained the purpose of the visit. SEE 9099-C Unsubstantiated The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview Resident#1-4 (R1 – R4), Interview with R1’s Responsible Party (RP), Interview with R1’s family, Interview with Montclair Hospital Social Worker (SW), Interview with VNA Care Nurse Liaison, copies of resident#1 (R1) Physician’s report dated 09/04/2024, Preplacement Appraisal Information dated 02/06/2025, Claremont Hacienda Observation notes from 01/15/2025 through 02/05/2025, Unusual Incident/Injury Reports from 01/28/2025 through 01/31/2025, Hospice Care Plan, Montclair Hospital Intake Summary, Consult Orders & Discharge Summary, and physical plant tour. The investigation revealed the following. Regarding Allegation: Staff did not accept resident back into care following hospitalization- It is alleged the facility refused to accept R1 back into the facility after R1 had a fall and was ready to be discharged by the hospital back to the facility. Review of R1’s facility record revealed, R1 was admitted into the facility on 12/03/2023. Review of Unusual Incident/Injury Report dated 01/31/2025, revealed R1 was found by staff, lying on their left side, with their head touching the bathroom floor. Staff called 911 and R1 was transported to Montclair Hospital. Facility staff notified R1’s primary care physician and responsible party. Interviews with R1’s family revealed R1 was ready to be discharged on 02/01/2025. R1’s family revealed facility staff refused to accept R1 back into the facility due to R1 having multiple falls and being a fall risk. During records review, LPA Ramirez reviewed R1’s hospital records. R1’s hospital records revealed on 02/01/2025, R1’s attending physician documented R1 had multiple falls prior to 02/01/2025 and now R1’s assisted living facility (ALF) is unable to accommodate for R1’s care. Two (2) out of the two (2) staff interviewed denied this allegation. Staff interviews revealed staff did not refuse to accept R1 back into the facility, however, staff needed to conduct a reappraisal on R1 before accepting them back into the facility. During the interview with the facility administrator, he stated he informed R1’s family members that a reappraisal was needed prior to the resident’s return to the facility. He also indicated a concern for readmitting R1 back to the facility since R1 had three falls in the past weeks prior to this last fall requiring hospitalization. Interviews with Montclair Hospital Social Worker (SW) revealed they began looking for new placement for R1 due to the facility refusing to accept R1 back into the facility after 02/01/2025. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 02/04/2025 and R1’s family has been in contact with VNA trying to find another board and care facility for R1 since R1’s facility was refusing to take R1 back. The VNA Nurse also stated the family did not want R1 to go to a Skilled Nursing Facility, therefore, the doctor ordered hospice for R1. The facility completed the reappraisal on 2/6/25, was informed the resident would be placed on hospice requiring 24-hour nursing care and ultimately accepted R1 back to the facility on 2/8/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 9, 2025 · control 28-AS-20250206153352

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Other on 05/09/2025, due to the pending closure of facility on 5/21/2025. LPA was greeted by Administrator Ricardo Lara-Perez and LPA explained the purpose of the visit. LPA Ramirez conducted a physical plant inspection and inspected food supply. Facility staff were observed providing care and supervision. Administrator Lara-Perez revealed Long Term Care Ombudsman (LTCO) has been assisting the facility with relocation of some residents. Administrator Lara-Perez revealed caregivers are on 12hr shifts. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Staff did not accept resident back into care following hospitalization.

*This is a corrected version of previously dated report 03/1/2025. Findings have changed from Substantiated to Unsubstantiated. LPA Ranirez re-delivered findings on 04/26/2025. * Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/13/2025 regarding the above allegation, to deliver findings. LPA Ramirez conducted initial complaint investigation on 02/07/2025 and a need further was documented. LPA was greeted by Administrator Ricardo Lara Perez and explained the purpose of the visit. Unsubstantiated The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview Resident#1-4 (R1 – R4), Interview with R1’s Responsible Party (RP), Interview with R1’s family, Interview with Montclair Hospital Social Worker (SW), Interview with VNA Care Nurse Liaison, copies of resident#1 (R1) Physician’s report dated 09/04/2024, Preplacement Appraisal Information dated 02/06/2025, Claremont Hacienda Observation notes from 01/15/2025 through 02/05/2025, Unusual Incident/Injury Reports from 01/28/2025 through 01/31/2025, Hospice Care Plan, Montclair Hospital Intake Summary, Consult Orders & Discharge Summary, and physical plant tour. SEE 9099-C The investigation revealed the following. Regarding Allegation: Staff did not accept resident back into care following hospitalization- It is alleged the facility refused to accept R1 back into the facility after R1 had a fall and was ready to be discharged by the hospital back to the facility. Review of R1’s facility record revealed, R1 was admitted into the facility on 12/03/2023. Review of Unusual Incident/Injury Report dated 01/31/2025, revealed R1 was found by staff, lying on their left side, with their head touching the bathroom floor. Staff called 911 and R1 was transported to Montclair Hospital. Facility staff notified R1’s primary care physician and responsible party. Interviews with R1’s family revealed R1 was ready to be discharged on 02/01/2025 and family tried multiple times to get R1 back into the facility on 02/01/2025. R1’s family revealed facility staff refused to accept R1 back into the facility due to R1 having multiple falls and being a fall risk. During records review, LPA Ramirez reviewed R1’s hospital records. R1’s hospital records revealed on 02/01/2025, R1’s attending physician documented R1 had multiple falls prior to 02/01/2025 and now R1’s assisted living facility (ALF) is unable to accommodate for R1’s care. Two (2) out of the two (2) staff interviewed denied this allegation. Staff interviews revealed staff did not refuse to accept R1 back into the facility, however, staff needed to conduct a re-assessment on R1 before accepting them back into the facility. Staff interviews revealed no other staff was available to conduct R1’s re-assessment until 2/6/25. Interviews with Montclair Hospital Social Worker (SW) revealed they began looking for new placement for R1 due to the facility refusing to accept R1 back into the facility after 02/01/2025. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. SW revealed R1 did not require skilled nursing care and R1 was placed on hospice care on 02/04/2025. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 02/04/2025 and R1’s family has been in contact with VNA trying to find another board and care facility for R1 since R1’s facility was refusing to take R1 back because they were a fall risk. LPA Ramirez reviewed R1’s reassessment conducted by the facility on 02/06/2025. On 02/08/2025, R1 was accepted back into the facility. Although the facility did take 6 days to complete R1’s re-assessment and 2 additional days to accept R1 back into the facility, R1 was ultimately accepted back into the facility following hospitalization. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 26, 2025 · control 28-AS-20250206153352

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Incident on 04/15/2025, due to Unusual Incident/Injury Report (LIC 624) received on 03/31/2025. LPA was greeted by Erika Montoya-Assistant Administrator and LPA explained the purpose of the visit. According to Unusual Incident/Injury Report (LIC 624) received on 03/31/2025, residents#1 & 2 (R1 & R2) got into a physical altercation on 03/28/2025. R1 suffered visible facial injuries. 911 was called and officer Chang from Claremont PD arrived. No arrests were made. Claremont Police incident report# 2500678 was provided to facility staff for reference. R1 and R2 were sent to the hospital. R1 & R2 returned to the facility on 03/28/2025 with an order to follow up with PCP. Records reviewed revealed facility staff notified R1 and R2’s responsible party, and primary care physician (PCP) on 03/28/2025 about the incident. R1 & R2 were roommates prior to the incident. Upon arrival back to the facility, R2 was relocated to another room. There have been no further incidents between R1 & R2. LPA Ramirez requested and obtained copies of residents#1-2 (R1- R2): Physician’s Report (LIC 602A), Appraisal/Needs and Services Plan (LIC 625), and facility staff observation notes. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Other on 04/15/2025, due to the pending closure of facility on 5/21/2025. LPA was greeted by Erika Montoya-Assistant Administrator and LPA explained the purpose of the visit. LPA Ramirez conducted a physical plant inspection and inspected food supply. LPA Ramirez observed staff conducting seated exercises with residents in facility living room. Facility staff were observed providing care and supervision. Interview with Assistant Administrator Erika Montoya revealed facility staff are working 12 hours shifts to ensure resident care is not compromised. Montoya revealed Long Term Care Ombudsman (LTCO) has been assisting the facility with relocation of some residents. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Staff mishandled the resident medications. Staff unlawfully evicted the residents. Staff did not provide adequate care and supervision to the residents.

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Initial 10-Day complaint investigation visit regarding the above allegations. LPA met with Administrator, Ricardo Lara Perez and explained the reason for the visit. Investigation consisted of: Facility submitted a copy of the resident roster and staff roster. LPA interviewed Administrator, Staff #1 (S1) to Staff #3 (S3), and Resident #1 (R1) to Resident #7 (R7). LPA reviewed medication records and Medication Administration for R1 to Resident #5 (R5). LPA reviewed and obtained documents from S1 and S2 files that include: First Aid Training, ongoing staff, and Medication Management Training. LPA also obtained the eviction letter that was sent to all responsible parties dated 2/21/2025. [Continued in LIC-C] Unsubstantiated Investigation revealed the following: Allegation: Staff mishandled the resident medications. It is alleged that the facility has no LVN available to disperse meds to the clients. During today’s visit, LPA interviewed the Administrator and three (3) out of three (3) staff and they all denied the allegation. Seven (7) out of seven (7) residents interviewed denied the allegation. Based on record review and interview, there are no disciplinary documentation for the S1 to S3 files. During the visit, LPA reviewed R1 to R5’s medication and Electronic Medication Administration Record (eMAR) with S2 and all medications are given as prescribed. Based on staff interview, Administrator stated that the former LVN’s last day of employment 3/13/2025. At that time until the present, the facility had trained Med Techs to provide medications for all residents. The new LVN will begin work on 3/19/2025. Based on staff and resident interviews, record review, there was insufficient evidence to corroborate with the allegations. Allegation: Staff unlawfully evicted the residents. It is alleged that the licensee gave the residents a 90-day notice to move out and the licensee is planning to close the facility. The Administrator, three (3) out of three (3) staff interviewed denied the allegation. Six (6) out of seven (7) residents interviewed denied the allegation. One (1) out of seven (7) residents interviewed stated not knowing about the eviction but indicated that resident’s responsible party most likely would know about the eviction and the facility closing. Based on staff interview, the Administrator was granted approval and sent the letters to all residents’ responsible parties on February 21, 2025, by postal mail regarding the facility closing on May 21,2025. Based on staff interview, the Administrator stated that the residents were informed one to one regarding the closure of the facility and that the facility plans to help provide assistance in finding a placement. Therefore, there was insufficient evidence to corroborate with the allegations. Allegation: Staff did not provide adequate care and supervision to the residents. It is alleged that the residents are left to help themselves and the current residents need skilled care to provide resources. The Administrator, three (3) out of three (3) staff interviewed denied the allegation. Seven (7) out of seven (7) residents interviewed denied the allegation. Based on staff and record review and interview, there are two (2) caregivers and one (1) med tech on duty per shift. All residents indicated that there are sufficient staff available to help provide care and supervision to meet their needs. LPA observed at the facility activity area that the residents were being closely supervised by the care staff and activity coordinator and that there were no immediate health or safety concerns. Therefore, there was insufficient evidence to corroborate with the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED. No deficiencies were cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided to the Administrator, Ricardo Lara Perez.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 28-AS-20250314102426

Allegation investigated: Staff did not accept resident back into care following hospitalization.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/13/2025 regarding the above allegation,to deliver findings. LPA Ramirez conducted initial complaint investigation on 2/7/25 and a needs further was documented. LPA was greeted by Administrator Ricardo Lara Perez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview Resident#1-4 (R1 – R4), Interview with R1’s Responsible Party (RP), Interview with R1’s family, Interview with Montclair Hospital Social Worker (SW), Interview with VNA Care Nurse Liaison, copies of resident#1 (R1) Physician’s report dated 09/04/2024, Preplacement Appraisal Information dated 02/6/2025, Claremont Hacienda Observation notes from 01/15/2025 through 02/05/2025, Unusual Incident/Injury Reports from 01/28/2025 through 01/31/2025, Hospice Care Plan, Montclair Hospital Intake Summary, Consult Orders & Discharge Summary, and physical plant tour. SEE 9099-C Substantiated The investigation revealed the following. Regarding Allegation: Staff did not accept resident back into care following hospitalization- It is alleged the facility refused to accept R1 back into the facility after R1 had a fall and was ready to be discharged by the hospital back to the facility. Review of R1’s facility record revealed, R1 was admitted into the facility on 12/03/2023. Review of Unusual Incident/Injury Report dated 1/31/2025, revealed R1 was found by staff, lying on their left side, with their head touching the bathroom floor. Staff called 911 and R1 was transported to Montclair Hospital. Facility staff notified R1’s primary care physician and responsible party. Interviews with R1’s family revealed R1 was ready to be discharged on 2/1/25 and family tried multiple times to get R1 back into the facility. R1’s family revealed facility staff refused to accept R1 back into the facility due to R1 having multiple falls and being a fall risk. During records review, LPA Ramirez reviewed R1’s hospital records. R1’s hospital records revealed on 2/1/25, R1’s attending physician documented R1 had multiple falls prior to 2/1/25 and now R1’s assisted living facility (ALF) is unable to accommodate for R1’s care. Two (2) out of the two (2) staff interviewed denied this allegation. Staff interviews revealed staff did not refuse to accept R1 back into the facility, however, staff needed to conduct a reassessment on R1 before accepting them back into the facility. LPA Ramirez reviewed R1’s reassessment conducted by the facility on 2/6/2025. Interviews with Montclair Hospital Social Worker (SW) revealed they began looking for new placement for R1 due to the facility refusing to accept R1 back into the facility after 2/1/25. SW revealed R1’s family was distressed due to the urgency to find new placement for R1 in such short notice. SW revealed R1 did not require skilled nursing care and R1 was placed on hospice care on 2/4/25. Interview of VNA Care Nurse Liaison revealed R1 was accepted into hospice care on 2/4/2025 and R1’s family has been in contact with VNA trying to find another board and care facility for R1 since R1’s facility was refusing to take R1 back because they were a fall risk. On 2/8/2025, facility staff accepted R1 back into the facility. Although the staff accepted R1 back into the facility on 2/8/2025, staff allowed 6 days to pass before arranging or assisting in arranging R1 with incidental medical care, back into the facility. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. LPA Ramirez will issue a Type A violation based on this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 28-AS-20250206153352

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 14, 2025

Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The licensee did not meet this requirement as evidenced by: facility staff allowed 6 days to pass before arranging or assisting R1'sthe state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: incidental medical care. Administrator agreed to draft plan on re-training by 3/14/25. Proof of staff re-training will be sent to LPA Ramirez 3/27/25, via email.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Daniel Konishi conducted a complaint visit at 8:50am. During the course of the investigation related to Complaint Control Number: 28-AS-20250311170813, Based on record review, Staff #1 was not associated to this facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator, Ricardo Lara Perez.the state’s words, verbatim · CDSS document, Mar 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 14, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, Staff #1 (S1) was not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator will associate Staff #1 immediately via Guardian and send proof to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management visit on 03/13/2025, due to the facility closing on 05/21/2025. LPA Ramirez was greeted by Administrator Ricard Lara Perez and explained the purpose of the visit. LPA Ramirez toured facility with Administrator Lara Perez. During tour, LPA Ramirez observed the facility activities room and Wing C was closed and inaccessible to residents due to renovations. Per Administrator Lara Perez, activities are now being conducted in the facility family room. LPA Ramirez observed several residents watching T.V. and socializing in family room. LPA Ramirez observed several staff providing care and supervision to residents in care. LPA Ramirez toured kitchen and observed sufficient food supply. Administrator Lara Perez agreed to send LPA Ramirez updates of resident relocations at least once a week. No violations were cited during this visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Prelicensing

*This is corrected version of pre-licensing dated 12/10/2024. Correction required to list correct administrator. No other changes were made.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an announced pre-licensing visit and was greeted by Administrator Ricardo Lara Perez. LPA Ramirez explained the purpose of the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip coating in showers. Video surveillance was observed on the outside of the facility Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. SEE 809-C for continuation. 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 observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4 ) out of the four (4) personnel records reviewed. COMP III was reviewed with Administrator Ricardo Lara Perez. Pre-licensing is complete, and this facility has no deficiencies. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an announced pre-licensing visit and was greeted by Administrator Daisy Hernandez. LPA Ramirez explained the purpose of the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip coating in showers. Video surveillance was observed on the outside of the facility Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. SEE 809-C for continuation. 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 observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4 ) out of the four (4) personnel records reviewed. COMP III was reviewed with Administrator Ricardo Lara Perez. Pre-licensing is complete, and this facility has no deficiencies. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 68 Census (if any clients in care): 37 COMP II Participants: LOIS MASTROCOLA, RICARDO LARA PEREZ Interview Method: Telephone interview On November 25, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 26, 2024