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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:41:44 PM

Document Has Been Signed on 12/05/2024 05:41 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:PILGRIM PLACE IN CLAREMONTFACILITY NUMBER:
197607628
ADMINISTRATOR/
DIRECTOR:		RICHARD RODASFACILITY TYPE:
741
ADDRESS:625 MAYFLOWER ROADTELEPHONE:
(909) 399-5500
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 454CENSUS: 62DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Dawnyell Varela- Director of Assisted LivingTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Dawnyell Varela- Director of Assisted Living and discussed the purpose of today’s visit.

The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (55) residents in assisted living and seven (7) in memory care.

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 eight (8) rooms; of which five (5) in assisted living (Pitzer Lodge) and three (3) in memory care (Rauch Memory Care Homes). 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. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed evacuation chairs in stairways. Visitors and staff are screened for covid-19 symptoms and temperature are taken prior to proceeding with their visit. The facility keeps a visitor and staff log with the daily covid-19 screening.

See 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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: PILGRIM PLACE IN CLAREMONT
FACILITY NUMBER: 197607628
VISIT DATE: 12/05/2024
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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). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets.

Planned Activities: LPA Ramirez observed a calendar for December of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care.

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 evacuation chair in stairway. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez 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.

Due to time constraints, LPA Ramirez will return to conduct subsequent annual inspection, at a later time. No deficiencies were cited at this time. Exit interview was conducted with Dawnyell Varela. A copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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