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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607628
Report Date: 01/23/2024
Date Signed: 01/23/2024 04:16:51 PM


Document Has Been Signed on 01/23/2024 04:16 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 CLAREMONTFACILITY NUMBER:
197607628
ADMINISTRATOR:RICHARD RODASFACILITY TYPE:
741
ADDRESS:625 MAYFLOWER ROADTELEPHONE:
(909) 399-5500
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:454CENSUS: 51DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dawnyell Varela- Director of Assisted LivingTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA Ramirez was met by 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 51 residents in the Assisted Living section and 8 in the Memory Care unit.
Observations:

* 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. No hazards were observed near walkways.
* All doors have signage posted to promote masking and symptom checks. LPA Ramirez observed signs on hallways, common areas, and bathrooms with COVID-19 signage and information. LPA Ramirez observed cough/sneeze etiquette signage.
* Visitors and staff 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. The facility is currently in an active COVID-19 outbreak.
* There are hand sanitizer stations located by each entry/exiting door.
* There is an isolation room (room #5) 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 in Pitzer hub hallway closet.
* Staff were observed wearing N95 mask and face shield. Residents and visitors were observed wearing face masks.
* Food supplies of 2 day perishable and at least a week of nonperishable were observed.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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: 01/23/2024
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* LPA Ramirez toured five (5) resident rooms at random. Room#14 is currently unoccupied. Water temperature taken in bathroom was measured at 116.2 degree F. Room#18 is currently unoccupied. Water temperature taken in bathroom was measured at 117.0 degree F. LPA Ramirez observed "RED ZONE" sign above room#103 and #311. LPA Ramirez observed plenty of PPE, hand sanitizer, Thermometer, shoe covers and red bags outside of these doors. LPA Ramirez observed trash can inside of room near entry.
* 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 Ramirez toured three (3) resident bedrooms and observed all these bedrooms to contain required lighting, linen, and furnishings. Bathroom water temperature in house#1 was measured at 108.3 degree F.

LPA Ramirez will return at a later time to complete full annual.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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