<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 01/02/2025
Date Signed: 01/02/2025 05:16:04 PM

Document Has Been Signed on 01/02/2025 05:16 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: 64DATE:
01/02/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Dawnyell Varela- Director of Assisted LivingTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent required annual inspection on 01/02/2025. LPA Ramirez conducted initial required annual inspection on 12/05/2024. 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 nine (9) in memory care.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Operational Requirements: 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 nine(9) in memory care.



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 five (5) out of the six (6) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6) out of the six (6) personnel records reviewed. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez reviewed food handler certificates for kitchen staff.

Staffing: Administrator Certificate for Richard Rodas expires on 6/15/2026.



Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.
SEE 809-C.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/02/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for Resident #1 (R-1) through Resident #8 (R-8). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

No violations were observed during this annual inspection. Exit interview was conducted. A copy of this report will be provided vial email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2