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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:35:36 PM


Document Has Been Signed on 04/11/2023 01:35 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
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: 314DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dawnyell VarelaTIME COMPLETED:
01:45 PM
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Regional Manager (RM) Araceli Ramirez, and Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting a case management visit.

The case management visit was conducted in response to concerns from an independent living resident regarding the Pilgrim Place community safety measures in place regarding active shooter(s). On today's visit, RM and LPA met with Dawnyell Varela director of assisted living, Mark Claiborne director of dining services, Odie Tollefson Human Resourcer and dining director, Jim Butler Board of Director, and Ron Bolding President and CEO.

During today's visit, RM and LPA observed the independent living dining area, and 6 entrance and exits to the dining area, toured the Pilgrim Place campus, and discussed the response that the community has taken regarding resident safety concerns. The community has reached out to the Claremont Fire Department and the Claremont Police department. The community is unable to lock the dining room doors, because doing so would create a fire safety hazard. Pilgrim Place conducts bi-annual active shooter training for all residents and staff, as well as monthly safety training(s). Pilgrim place also has security on site, that patrol the community on carts.

There were no deficiencies observed. Exit interview conducted, and copy of report provided to Ms. Varela.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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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