197607628-4-12-2023-28-AS-BPEA-CQTPTD-20230412113547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607628
Report Date: 02/22/2023
Date Signed: 04/12/2023 11:35:44 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221223120948

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: 40	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Richard Rodas, Administrator/VP Health Services		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff hit resident with an object while in care resulting in bruising.

INVESTIGATION FINDINGS:

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*****This report serves as an amendment and supersedes the original complaint investigation report dated 2/22/2023. The reason for amendment is to make corrections to LIC9099-D. Investigation findings remain the same.******

Licensing Program Analyst (LPA), Bennette Pena conducted the subsequent complaint investigation for the allegation listed above. LPA met with Richard Rodas, Administrator/VP Health Services and explained the purpose of the visit. Staff conducted covid screening upon entry.

On 12/28/2022, LPA Pena conducted the initial complaint visit and obtained copies of the Staff/Resident roster, Resident #1 (R1) files such as: Face sheet (ID and Emergency Info.), Resident appraisal (LIC603A), Physician’s report (LIC802A), Appraisal needs & services plan, R1's care plan, Incident report & statement and interviewed Staff #1-2 (S1-2).

During today's visit, LPA Pena obtained copies of the current staff/resident roster, LA County DA Office letter addressed to R1 , attempted to interview Staff #3 (S3) 3x who is no longer employed at the facility as of 5/15/2022, but calls were never returned.LPA interviewed Staff #4-Staff #5 (S4-S5) and Resident #2-Resident #6 (R2-R6). *****CONTINUATION ON LIC9099-C*****

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221223120948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/22/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff hit resident with an object while in care resulting in bruising. it is alleged that a staff hit a resident's left hand which resulted in bruising. Interviews conducted with 2 out of 4 facility staff revealed that facility staff have never hit any resident and stated that they have not heard or witnessed any staff member hitting a resident. 2 out of 4 facility staff interviewed stated that they were aware of that type of incident had happened in the facility. S1 stated that he was aware of the incident because a staff reported an abuse allegation to him and they immediately conducted an investigation. S2 confirmed the allegation and stated that she witnessed the incident because she was working alongside S3 when it happened. S2 also stated that she told S3 to stop and that she should not hit R1. S2 reported it to her Supervisor who in turn reported the incident to S1. S2 also stated that she saw the bruising on R1's left hand slowly fading away days after the incident. 5-5 interviewed residents stated that they were never hit nor physically abused by any staff member. All 5 residents also stated that they did not hear, or have see any staff member hitting another resident.

Based on LPA’s investigation, interviews, and record reviews, it was determined that S3 had violated the personal rights of R1 when S3 hit R1 with the CPAP cord on 5/10/2022 resulting in a bruise and the preponderance of evidence standard has been met. This incident was witnessed by S2 and reported as required. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights provided, and copy of the report provided to the Administrator/VP of Health Services, Richard Rodas.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221223120948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all ...facilities for the elderly shall .....personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, .... This deficiency was evidenced by the following:	1 2 3 4 5 6 7	Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.
	8 9 10 11 12 13 14	Based on investigation, interviews and records review, S3 did not comply with the section cited above in that S3 violated the personal rights of R1 when S3 hit R1 with the CPAP cord on 5/10/2022 resulting in a bruise which poses an immediate Health, Safety, or Personal Rights risk to residents in care. This incident was witnessed by a staff and reported as required.	8 9 10 11 12 13 14	Administrator will provide in-service training to staff and residents on section 87468.1 and submit a copy of the agenda and sign in log to the department by 3/03/2023.
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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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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