197607628-11-9-2023-28-AS-RORN-CXRVH6-20231120152638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607628
Report Date: 08/31/2023
Date Signed: 11/09/2023 09:12:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2023 and conducted by Evaluator Valeria Maldonado

COMPLAINT CONTROL NUMBER: 28-AS-20230811152710

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:	DATE:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Dawnyell Varela- Director of Assisted Living		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not prompt resident to shower.
Staff did not assist resident with physical therapy.
Staff administered incorrect medication to resident.

INVESTIGATION FINDINGS:

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**Please note: This report has been amended for the purpose of removing confidential information listed on the intial report. However, all other information of the intial report, including the findings will remain the same- Unsubstantiated.**
Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of delivering an amended report regarding the above-mentioned allegations. During today's visit, LPA Maldonado met with Director of Assisted Living, Dawnyell Varela, and explained the purpose for the visit.
On 8/18/23, LPA's V. Maldonado and Sanjay Vaid conducted an initial complaint visit to the facility and met with Director of Assisted Living Dawyell Varela. The visit cosisted of the following: LPA's obtained a copy of the resident and staff rosters, and the following documents for Resident# 1 (R1): Facesheet, Pre-Placement Appraisal, Needs and Services Plan, Functional Assessment, Shower Logs for June-July 2023, Medication Administration Records (MARs) for June-July 2023, Incident Reports for June-July 2023, and Physical Therapy Records. LPA's also interviewed Staff# 1-5 (S1-S5) and Residents# 1-2 (R1-R2).
(Report Continued on LIC9099-C....)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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-20230811152710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CLAREMONT	FACILITY NUMBER: 197607628
	VISIT DATE: 08/31/2023

NARRATIVE

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On 08/31/23, LPA Maldonado conducted interviews with Residents# 3-6 (R3-R6) and reviewed medications for R1. The investigation revealed the following:
Regarding allegation: Staff did not prompt resident to shower.
It is alleged that R1 is not being prompted to shower when they refuse. LPA was not provided shower logs due to the facility not keeping any. However, a shift assignment note dated 8/14/23 was provided that indicates that R1 accepted a shower and another note, that is not dated, that indicates R1 refused a shower. Per interviews conducted, (4) of (5) staff stated R1 has refused showers in the past, but they encourage whenever possible and don't force residents to do what they do not want. Per the interview with R1, it was stated that staff assist with showers and R1 receives minimal assistance as is able to do it alone. (5) of (5) Residents interviewed stated they are unaware of an incident where a resident was not prompted to shower.
Regarding allegation: Staff did not assist resident with physical therapy.
It is alleged that when R1 was becoming weak, the facility did not do anything to assist the resident with doing exercises or physical therapy. After review of R1's Physician's Report, it has been noted that R1 is non-ambulatory and requires assistance to walk with a walker. Per the interview with R1, R1 received physical therapy on the day of the initial visit, 8/18/23, takes daily walks around the facility grounds on their own, and likes to join in activities when R1 feels like it. (5) of (5) staff state that R1 did not require physical therapy and if ever required assistance with getting around, staff would assist and supervise. (5) of (6) residents could no corroborate the allegation. Residents interviewed stated staff are always around and are willing to assist however they can with requests and needs.
Regarding allegation: Staff administered incorrect medication to resident.
It is alleged that R1 may have been given the wrong medication, which resulted in R1 hallucinating and acting strange. Per R1's MARs and medication review, it was discovered that R1's medications are being administered and documented properly by the facility staff. Per interviews conducted, (5) of (5) staff denied administering wrong medications to residents, or seeing R1 acting strange or expressing hallucinations. R1 stated to have no concerns with the way medications are administered or concerns with staff giving something different than R1's medications. R1 stated to be aware of the medications R1 takes. (5) of (6) residents denied the allegations and stated the facility staff are consistent with giving medications daily and as needed.
Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are Unsubstantiated.
Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.
An exit interview was conducted with Dawnyell Varela and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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