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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:45:58 PM


Document Has Been Signed on 01/29/2024 02:45 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:RICHARD RODASFACILITY TYPE:
741
ADDRESS:625 MAYFLOWER ROADTELEPHONE:
(909) 399-5500
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:454CENSUS: 58DATE:
01/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Dawnyell Varela- Director of Assisted LivingTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 01/23/24. LPA met with Dawnyell Varela (Director) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the following domains:

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Richard Rodas expires 06/15/24 (6041259740). Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA reviewed personnel records for eight (8) personnel. Pertinent staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training including required initial and annual training. Staff#2 (S2) was short 2 hours of Dementia training. LPA Ramirez will issue Technical Violation.

Resident Rights-Information: Resident rights are posted and included in Resident files. Let-Us-No poster posted. LTCO poster posted.

Resident Records: LPA reviewed six (6) resident records. 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.

One (1) Technical Violation is being cited today. Exit interview is conducted with Dawnyell Varela. A copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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