197607628-12-1-2022-28-AS-CDCN-CLPT9V-20221201133233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:32:48 PM

Document Has Been Signed on 12/01/2022 01:32 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 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: 60	DATE:	12/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Dawnyell Varela, Administrator		TIME COMPLETED:	01:35 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) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. Program Clinical Consultants Toni Rivera and Anna Guinto were also present for the visit. LPA met with Administrator, Dawnyell Varela, and explained the purpose of the visit. The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. There is a fire clearance for 252 ambulatory, 106 non-ambulatory, and 96 bedridden. The facility may accept or retain 10 hospice residents. There are 56 residents in the Assisted Living section and 4 in the Memory Care unit. During the tour today, the following were observed: * Pitzer Lodge Assisted Living unit consists of separate buildings called the Pitzer South, Pitzer North, Pitzer East, and the Pitzer Friendship Court. The buildings appeared to be well maintained and nothing obstructing the walkways. * All doors have signage posted to promote masking and symptom checks. Hallways, common areas, bathrooms have proper COVID-19 signage. LPA recommended for the cough/sneeze signage to be added to the buildings. * Visitors are screened for covid-19 symptoms and temperature are taken prior to proceeding with their visit. The facility keeps a visitor and staff log with the daily covid-19 screening. * Facility keeps a binder with current Provider Information Notices (PINs) by the Pitzer South entrance for reference. * There are hand sanitizer stations located by each entry/exiting door. * There is an isolation room (room #2) set aside to quarantine a COVID-19 positive individual if needed. * The facility has ample supplies of PPE such as gowns, gloves, surgical masks, N95, and face shields. * All staff and residents (if tolerable) were wearing face masks. * Food supplies of 2 day perishable and at least a week of nonperishable were observed.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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
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: 12/01/2022

NARRATIVE

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* Per the Administrator, the housekeepers disinfect high touched surfaces at least 2x per shift.
* The Memory Care Unit (Rauch Houses) is a separate building located within proximity to the Assisted Living unit. COVID-19 screening questionnaire is given to all visitors and staff upon arrival. Knives, cleaning supplies, and medications are locked, making them inaccessible to residents. LPA recommended to have paper towel and soap readily available inside the laundry area.

No deficiencies were issued during the visit today. An exit interview was held and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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