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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 11/07/2022
Date Signed: 11/09/2022 09:12:22 AM


Document Has Been Signed on 11/09/2022 09:12 AM - 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: 4DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director of Assisted Living-Dawnyell VarelaTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management visit. LPA met with Director of Assisted Living Dawnyell Varela acting as Director of Memory, Nursing Supervisor Rosie Linarez and Vice President of Health Services Rich Rodas and discussed the purpose of the visit. LPA is following up on Incident Report dated 10-21-22, regarding the unsupervised wandering of Resident #1 (R1).

The visit consisted of interviews with Staff #1 (S1), Staff #2 (S2), Witness #1 (W1) and Resident #1 (R1). LPA requested and obtained Dementia Plan of Operation, Dementia training for caregivers, Facility Personnel Roster for 10-21-22, Resident Roster, Resident 1 (R1) File, Personnel files, R1 Physician Report, and written statement by staff.

Director of Assisted Living Dawnyell Varela and Nursing Supervisor Rosie Linarez, assisted with tour of memory care cottage (Rauch House) located on the northwest corner of the campus. The Plan of Operation for the 6-bed Rauch House states that the Licensee will advertise dementia care and caregivers in the Rauch House will posses the required training. The Rauch House is encompassed by a 6-foot fence around the backyard with a service gate. The home consists of four (4) bedrooms: 2 private & 2 semi-private; 2 full bath bathrooms, dining area, kitchen, living room, laundry area, an outdoor patio area with furniture to accommodate the residents (including a wander path for leisure walking). The facility is equipped with a SARA System that is tied into the facility staff pagers. LPA observed all walkways to be clear and free of hazards. LPA observed a central entry gate to locked and required a passcode from staff to enter. LPA observed the main entry gate to sound an alarm with a 15 second delay, until the gate opens.
*Continued on 809C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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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Document Has Been Signed on 11/09/2022 09:12 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Based on observations, the licensee did not comply witrh the section cited above in that the resident was able to wander away from the facility unsupervised and without detection from staff, which pose/posed a potential health, safety or potential rights to persons in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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
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: 11/07/2022
NARRATIVE
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On October 21, 2022, at approximately 5:55 a.m., S1 was waking up from a nap in her vehicle which was parked on Eight St. S1 noticed something or someone laying in the middle of the road. S1 turned on her car headlights and saw that it was a woman. At approximately 6:10 a.m., male witness (W1) approached the woman and S1 to render assistance. S1 realized that the woman was a resident of the home. W1 attempted to assist R1 back on her feet but, R1 kept falling to her hands and knees after a few steps. At 6:35 a.m., S1 walked into the home to alert S2 that R1 was outside the facility and unsupervised. S2 stated that she was aware and that at 6:26 a.m., she notified Memory Care Director Rosaline Harris of R1 elopement. R1 was taken by paramedics to Pomona Valley Hospital for evaluation.

It was reported and confirmed by internal investigation that R1 wandered away from the facility unsupervised for approximately 20 to 30 minutes. As a result, from wandering away unsupervised from the facility, R1 suffered a fractured right wrist due to a fall. Although the facility is equipped with SARA System alarm; it was not noted to be in disrepair on or before 10-21-22, it is unclear how R1 was still able to wander away without detection from staff.

LPA was notified during the tour of the facility that 3 cameras with motion sensors have been added. An audible chime/alarm has now been placed on main entry of door.

Based upon interviews and information obtained, deficiency cited on LIC 809D. Appeal rights explained and exit interview conducted with Dawnyell Varela.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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