197607628-7-27-2021-28-AS-LMAZ-C5BQHX-20210727121151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:12:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PILGRIM PLACE IN CLAREMONT		FACILITY NUMBER:	197607628
ADMINISTRATOR:	RICHARD RODAS		FACILITY TYPE:	741
ADDRESS:	625 MAYFLOWER ROAD		TELEPHONE:	(909) 399-5500
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	454	CENSUS: 6	DATE:	07/27/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rich Rodas, Vice President		TIME COMPLETED:	12:15 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 Analysts (LPA's), Linda Almaraz and Nina Galarza conducted a visit to the above facility for a PRE-LICENSING evaluation for 1 additional building which will be Memory Care. LPA's met with Vice President, Rich Rodas, Director of Memory Care, Rosaline Harris, CEO, Ron Boling, and Ted Morales, Director of Buildings and Grounds. An application was submitted to CCLD for an additional memory care building with a capacity of six (6). The building address is 704 1/2 W. 8th St, which is part of Pilgrim Place Campus. Structure: Facility is a (4) bedroom, (2) bathroom, single-story house. The home has a living room, dining room and large kitchen. There is a large, covered patio area with furniture and shade which is shared with 704 W. 8th St. memory care building. The residents bedrooms are spacious and will easily accommodate the resident's furnishings. Signal system: All exits doors are equipped with a sensor type alarm systems which alerts staff on their pagers. Bedrooms Residents: Bedrooms are approved for non-ambulatory residents. All bedrooms have the required bed(s), chair(s), night stand(s), lamp(s) in addition to overhead lighting. Each resident has a large closet with drawers.. Laundry Room: Laundry room is secured with washer and dryer. Laundry supply is secured and locked separately. Bathrooms: All bathrooms have a working toilet, wash basin, shower. There is one (2) bathrooms in the facility. (Continued on an LIC-9099-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PILGRIM PLACE IN CLAREMONT	FACILITY NUMBER: 197607628
	VISIT DATE: 07/27/2021

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blankets and bedspreads. Adequate supply of linen stored in the laundry room.

Emergency Phone Numbers, Exit Plan & Menu:
Facility’s telephone system is landline. Numbers posted & readily available for review. Fire Extinguishers located in the dining room, living and hallway.

Food Service:
Dishes, cups and utensils are stored in the kitchen inspected and in good repair. Food supply adequate for seven (7) days of non-perishables. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
Electrical & connected. Battery operated & working. Carbon monoxide detector located in the hallway and is operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There is two (2) refrigerators in the home, a small one is located in the medication room which will be utilized for refrigerated medication and one in the kitchen for food. Freezer is at (0) zero degrees Fahrenheit. The facility is equipped with central air and heating and each residents bedrooms are comfortable in temperature.

Water Temperature:
Tested at 114.6*F in bathroom #1 and 107.4*F degrees in bathroom #2 .

Medications, First-Aid Kit & Book:
A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first-aid manual, which are stored in the medication room, available for staff use but inaccessible to residents. (Continued on LIC 9099-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PILGRIM PLACE IN CLAREMONT	FACILITY NUMBER: 197607628
	VISIT DATE: 07/27/2021

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Residents Records & Staff Files:
Applicant will not be handling cash resources of residents, therefore no Surety Bond will be required. Records of staff and residents shall be stored in a locked cabinet.

Reading Material, Games, Equipment & Materials:
The facility has board games, exercise equipment, and other recreational materials for the resident's use, commensurate with the plan of operation.

Fire clearance:
Fire Clearance was approved on 4/14/21.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the Licensee Applicant Representative (Rich Rodas). Accordingly, LPA will submit a copy of this Facility Evaluation Report to the Central Applications Unit (CAU) for review. If Licensee Applicant Representative has questions regarding the status of the application, they have been instructed to communicate with their CAU Analyst assigned to process their application.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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