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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:39:09 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 CLAREMONTFACILITY NUMBER:
197607628
ADMINISTRATOR:RICHARD RODASFACILITY TYPE:
741
ADDRESS:625 MAYFLOWER ROADTELEPHONE:
(909) 399-5500
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:454CENSUS: 49DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dawnyell VarelaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Dawnyell Varela and explained the purpose of today's visit.

This is an RCFE - Continuing Care Retirement Community (CCRC). Facility serves elderly residents (age 60 and above). Facility is fire cleared for 252 Ambulatory, 106 Non-Ambulatory, and 96 Bedridden. Facility has an approved Hospice Waiver to retain/accept (10) residents. There currently are (49) residents in assisted-living: (2) hospice, (0) bedridden (0) exception, and (2) receiving home health. LPA also observed the residents during meal time (lunch).

The following was inspected and toured: Pitzer (South), Pitzer (North), Pitzer (East), and Pitzer (Friendship Court) which include: resident's studio, 1-bed room and/or 2-bed room apartments, with private bathrooms, living room, dining area, a commercial-size kitchen in the main building, indoor/outdoor activity areas. All residents’ apartments have the required furniture for privacy, comfort, and safety. Bathrooms were observed to be clean and operational (w/grab bars and non-skid surface/mats in place). Hot water temperature tested between 111*F degrees. Required notifications and postings were observed throughout the facility in the different buildings located on bulletin boards and all included: Resident Personal rights, Facility sketch, Visitor policy, complaint procedures, menu and emergency disaster plan.

The following was observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways throughout the facility.
  • Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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: 02/10/2022
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  • Residents are able to use their private accommodations as isolation rooms as all resident rooms are private and facility also has a designated COVID-19 isolation room that is available to be used for residents that have a shared room, such as couples, if a COVID-19 positive case should arise.
  • Per Administrator Varela, all Residents (Assisted Living and Memory Care) are fully vaccinated.
  • Per Administrator Varela, Staff are vaccinated. However, 1 staff is pending the booster.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Residents were socially distanced according to local public health guidelines.
  • Residents were observed wearing masks.
  • Facility has an adequate amount of PPE and facility has enough PPE for 6 months.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
  • Restrooms were observed to have sufficient soap, paper towels, hand sanitizer and signs promoting proper hand washing etiquette.
  • Facility has a laundry room that is designated as a COVID-19 laundry room if the facility has a positive case(s).
  • Residents temperature is checked and logged twice a day.
  • Staff temperatures are checked and logged twice a day.
  • Surveillance testing is conducted once a week.
  • Mass testing is conducted weekly if there is a positive case in the facility (includes independent living).
  • All facility staff is FIT Tested.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Dawnyell Varela and copy of report provided.

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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