Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to have an effective pest control
program, to prevent cockroaches in one of one kitchen for a facility licensed for a 59-bed count.
Residents Affected - Some
This deficient practice had the potential to expose 38 residents currently residing in the facility to foodborne
illness.
Findings
During a concurrent observation and interview on 2/11/25 at 1:15 p.m. while in the kitchen with the head
chef (HC), HC stated he has only been employed at the facility for a few weeks. HC stated he doesn't know
the last time the kitchen had a deep cleaning for the floors and all areas of the kitchen. HC stated the
kitchen crew does daily sweeping and mopping two times (once during the day and once in the evening
after dinner). During the tour of the kitchen, in the back of the cooking areas, there was grease and dirt
build up observed on the pipes. The kitchen exhaust hood was observed with grease and dirt build up on
the overhead fire sprinklers.
During an observation on 2/11/25 at 1:40 p.m. while in the kitchen near the dishwashing area, 4 gray
colored plastic compartment cup racks were stacked upon each other on the floor under the stainless-steel
table. When the trays were pulled aside from underneath the table, two cockroaches were observed
crawling on the lower wall. The wall, pipes, baseboard and tile floor all had white and brown residue build
up; the wall had black, brown and white residue/stains and the grout in the tile floor was black in color.
During an interview on 2/11/25 at 2:10 p.m. with the Infection Preventionist (IP), the IP stated there were no
reported instances of cockroaches in the resident's room or in the resident's food. IP stated she does a
walk-through in the kitchen once a month. IP stated she was aware that the kitchen was closed for 48 hours
due to cockroaches found in the kitchen. IP stated no food from the kitchen will be served to the residents
after lunch time on 2/11/25, and the facility's administration is working on who will provide food to the
residents for dinner on 2/11/25.
During a concurrent interview on 2/11/25 at 2:22 p.m. with the Director of Environmental Services (DES)
and the Housekeeping Supervisor (HKS), the DES stated a professional deep cleaning is performed by a
contracted vendor twice a year in the kitchen. The DES stated the last cleaning was completed on 8/12/24.
The HKS stated the housekeeping department does not clean the kitchen area; the kitchen/dinning staff
clean the kitchen daily. HKS stated housekeeping cleans the common areas used by the residents:
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555085
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claremont Manor Care Center
621 W Bonita Ave
Claremont, CA 91711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0925
bathrooms, showers, hallways, and resident's rooms.
Level of Harm - Minimal harm
or potential for actual harm
HKS stated she completes a work order or sends a notification e-mail to the Maintenance Department for
any facility repair needed.
Residents Affected - Some
DES stated he will be coordinating the vendor repair work in the kitchen to ensure entry points for any pests
are sealed.
During an interview on 2/11/25 at 2:41 p.m. with the Lead/Supervisor Kitchen (LSK), LSK stated she was
informed there is a 48-hour mandated kitchen closure. LSK stated, For today's dinner the facility contacted
a licensed vendor, and they will prepare and bring the food, which will be served in the dinner area. LSK
stated all food is being prepared offsite and will be served in disposable containers.
During an interview on 2/11/25 at 3:46 p.m. with the Administrator (ADMIN), the ADMIN stated the facility
does not have a pest control policy. The ADMIN stated he was new at the facility, and the ADMIN has only
been at the facility since December 2024. The ADMIN stated he would provide vendor receipts for pest
control services completed in 2024 and 2025. The ADMIN stated the facility follows the pest control
company's recommendations.
During a review of the facility's vendor receipts for pest control services, the Summary of Service (S0S)
dated 2/4/25, indicated, Kitchen area, recommendation: debris collecting under (food prep tables). Please
remove debris to prevent unsanitary conditions and attraction by pests. Severity = High; Status: Pending;
Date: 9/13/24. The SOS further indicated, Kitchen area, recommendation: pipes extending through wall
allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Severity = High;
Status: Pending; Date: 9/13/24.
During a review of the facility's policy and procedure (P&P) titled, Cleaning Protocol, dated, January 2017,
the P&P indicated, Policy: Housekeeping services will be routinely provided to provide a clean environment
which prevents the spread of infection. The P&P did not indicate cleaning of the kitchen area. The P&P
indicated the areas cleaned by housekeeping are resident's room (daily and terminal cleaning on
discharge), bathroom, nursing stations, central bath/shower rooms, physical therapy room, office areas,
public restrooms, storage rooms, and hallway areas.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention & Control Program,
revised, January 2024, the P&P indicated, Overview: Each skilled nursing (SNF) observes its adopted and
implemented Infection Prevention and Control Program (IPCP) with standard and transmission-based
precautions to be followed to provide a safe, sanitary and comfortable environment that helps prevent the
development, transmission and spread of communicable disease and infections. The P&P indicated, The
IPCP includes the following: Reviewing, establishing and monitoring environmental infection control
approaches in accordance with CDC/HIPAC/OSHA guidelines and local or state requirements to provide
the community with a safe and sanitary environment. The P&P further indicated, The IPCP includes the
following: Providing guidance for maintaining the community in a sanitary fashion: Reviewing food handling
practices, laundry practices, pest control, traffic control, visiting rules for high-risk areas and sources of
airborne infection.
During a review of the U.S. Food & Drug Administration Food Code, dated 2017, the food code indicated
under 6-501.111 Controlling Pests, Insects and other pests are capable of transmitting disease to humans
by contaminating food and food-contact surfaces. Effective measures must be taken to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555085
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claremont Manor Care Center
621 W Bonita Ave
Claremont, CA 91711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0925
eliminate their presence in food establishments.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555085
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the February 11, 2025 survey of CLAREMONT MANOR CARE CENTER?
This was a inspection survey of CLAREMONT MANOR CARE CENTER on February 11, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CLAREMONT MANOR CARE CENTER on February 11, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Make sure there is a pest control program to prevent/deal with mice, insects, or other pests."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.