197607628-4-25-2023-28-AS-RORN-CSZLY7-20230621090952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607628
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:02:45 PM

Unsubstantiated

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
04/17/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230417150324

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: 58	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Dawnyell Varela, Director of Assisted Living		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff are not qualified to administer medication.
Facility staff are not ensuring that residents are receiving medication(s) as prescribed.
Facility staff are not ensuring that residents are receiving an adequate daily food intake.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with the Director of Assisted Living, Dawnyell Varela. The purpose for the visit was explained.

LPA obtained copies of the resident and staff rosters, reviewed Staff files and medications for 6 Residents. Interviews were held with the Director of Assisted Living, Staff #1 - #5 (S1 – S5), and Resident #1 - #6 (R1 – R6).

The investigation revealed the following:
Allegation - Facility staff are not qualified to administer medication. Per Director Varela, the only staff that are handling medications are the Licensed Vocational Nurses (LVNs) and the Med Techs. LPA interviewed a total of 5 Staff. 2 of the staff indicated that they are licensed vocational nurses and can administer the insulin shots when needed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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-20230417150324

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: 04/25/2023

NARRATIVE

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They stated there is currently one resident who takes insulin injections. Per LVNs, they administer the injection to the resident when they are working. However, the resident will self-inject the insulin when a med tech is on duty and is documented on the back of the MAR log. The other 3 Staff stated that they do not handle or administer medications to residents, and that the LVNs/Med Techs are the only ones managing medications. LPA verified that the vocational nurse license for the 4 full-time LVNs are still current. LPA also verified that the Med Techs had medication training for this year. Interviews were conducted with 6 Residents. Residents stated they receive their medications only from the LVNs or Med Techs.

Allegation - Facility staff are not ensuring that residents are receiving medication(s) as prescribed. During the visit today, LPA reviewed the medication and the Medication Administration Record (MAR) log for 6 residents. There were no discrepancies found and it appears that residents are receiving their medications as prescribed. Per the medication staff, the residents have been consistently taking them and are distributed during meals or in their rooms. One of the staff indicated that when a resident informs them that he/she has not taken medications, the staff would contact the charge nurse right away. All 6 residents interviewed stated they get their medications on time daily and do not have any concerns.

Allegation - Facility staff are not ensuring that residents are receiving an adequate daily food intake. Per Director Varela, they ensure that residents are getting their meals daily. During mealtime, if a resident does not come to the dining room, the staff will first check the resident sign in/out log to confirm they are not out in the community. They will follow up with a phone call to the resident’s room before they go do a physical check. On a daily basis, residents will fill out the Pitzer Lodge Dining Room sheet to inform staff whether they want to reserve or cancel the 3 meals and/or to indicate tray service. LPA interviewed staff and they indicated they would always follow up to ensure residents get their meals. The residents interviewed all stated they eat their meals daily either in the dining room or in their rooms. They enjoy the food at the facility and have alternatives available to them.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
An exit interview was conducted with Dawnyell Varela. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC9099 (FAS) - (06/04)

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