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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607628
Report Date: 12/24/2024
Date Signed: 12/24/2024 04:01:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241218141114
FACILITY NAME:PILGRIM PLACE IN CLAREMONTFACILITY NUMBER:
197607628
ADMINISTRATOR:RICHARD RODASFACILITY TYPE:
741
ADDRESS:625 MAYFLOWER ROADTELEPHONE:
(909) 399-5500
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:454CENSUS: 56DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Dawnyell Varela- Director of Assisted LivingTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are storing spoiled food at the facility.
Staff did not ensure that the facility refrigerator was repaired.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 12/24/2024 regarding the above allegations. LPA was greeted by Dawnyell Varela- Director of Assisted Living and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 4 interviews (S1 – S4), Resident Interviews# 1-3 (R1-R3), work orders for walk-in refrigerator#1, email correspondence in regards to walk-in refrigerator #1, and physical plant tour.

See 9099-C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20241218141114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/24/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff are storing spoiled food at the facility – On 12/24/2024, around 9:15 am, LPA Ramirez toured Abernathy kitchen and Health Services Center (HSC) kitchen. Per staff interviews, Abernathy kitchen provides meals for the residents in assisted living and independent living. HSC kitchen provides meals for memory care residents and skilled nursing. During tour of both kitchens, LPA Ramirez did not observe perishables foods to be spoiled. Perishables stored in facility walk-in refrigerators were observed to have labels with dates indicating “use by date”. All walk-in refrigerators and walk-in freezers storing perishable foods 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). Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) out of the three (3) residents interviewed deny this allegation. 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.

Staff did not ensure that the facility refrigerator was repaired- During tour of HSC kitchen, LPA Ramirez observed walk-in refrigerator#1 to be locked and inaccessible. Staff opened refrigerator upon request and LPA Ramirez observed the refrigerator to be in empty. Staff interviewed collaborated the walk-in refrigerator in HSC kitchen has been in disrepair for weeks, but the facility placed a work order for the repair as soon as staff observed a change in temperature and is awaiting a replacement unit and budget approval. Staff interviewed revealed all perishable foods that were stored in this walk-in refrigerator, were immediately moved to another walk-in refrigerator in HSC kitchen. LPA Ramirez reviewed several invoices indicating the facility’s continued attempts to repair walk-in refrigerator#1 in HSC kitchen. Records reviewed, showed initial repairs were made however, additional parts were required to complete the repair. LPA Ramirez reviewed email correspondence by maintenance staff submitting work orders for walk-in refrigerator#1, attempts to repair walk-in refrigerator#1 and quotes to replace walk-in refrigerator#1 in HSC kitchen. 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.



No violations were observed during this investigation complaint. Exit interview was conducted. A copy of this report was provided via email.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2