Pilgrim Place in Claremont

Allegation investigated: Staff do not respond to residents' requests for assistance in a timely manner. Staff members are under the influence of drugs while providing care.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit at the facility for the purpose of completing the investigation regarding the above-mentioned allegations. During today's visit, LPA Lopez met with Director of Assisted Living, Dawnyell Varela, and explained the purpose for the visit. On 8/03/23, LPA Lopez conducted an initial complaint visit to the facility and met with Director of Assisted Living Dawnyell Varela. The visit consisted of the following: LPA obtained a copy of the resident and staff rosters, and interviewed Staff #1 and #2 (S1, S2) During today's visit, LPA Lopez conducted interviews with 4 Staff#3-#6 (S3-S6) and six Residents #1-#6 (R1-R6) and six witnesses W#1-W#6 (W1-W6) including family members of residents. LPA toured Pitzer Lodge South and inspected six random rooms. Unsubstantiated The investigation revealed the following. Allegation: Staff do not respond to residents' requests for assistance in a timely manner. It is alleged that staff do not respond to calls for assistance from residents in timely manner and that staff mistreat residents. LPA Lopez interviewed six staff members and all 6 of 6 staff members denied the allegations. LPA interviewed six residents and 6 of 6 residents could not collaborate the allegations. LPA interviewed five witnesses including family members and 6 of 6 witness could not collaborate the allegations. All 6 residents stated that they get prompt service and are never mistreated by staff. All the residents stated they are very happy living at facility. Witnesses all stated that the residents get prompt attention and are treated well. They have never heard residents raise any concerns over how long it takes staff to assist residents or how are treated. LPA tested call light response in resident’s rooms and the response time was under a minute. LPA obtained and reviewed incident reports that log in call response time from 7/30/23, 07/31/23, 08/01/23, 8/02/23, 09/30/23 and 10/01/23 – 10/18/23 and the average response time on the log was under 5 minutes. LPA did not discover any evidence to support the above allegation. Allegation: Staff members are under the influence of drugs while providing care. It is alleged that staff are under the influence while providing care. LPA interviewed 6 staff and 6 of 6 staff denied the allegations. LPA interviewed 6 residents and 6 of 6 residents could not collaborate the allegations. Several residents expressed shock to hear the allegation. Some residents stated they would be able to tell if that was happening. LPA interviewed 6 witnesses and 6 of 6 witness could not collaborate the allegations. Several witnesses stated they have never observed staff being under the influence while visiting. Several witnesses stated they are mandated reporters and would report that if they observed any staff being under the influence while providing care. LPA did not observe any evidence of staff being under the influence during the entire visit. 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. An exit interview was conducted with Director of Assisted Living and findings were discussed. A copy this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20230724144559

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

**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 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.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 28-AS-20230811152710

Allegation investigated: Staff neglect led to resident suffering from multiple UTIs Staff did not seek medical attention for resident in a timely manner Staff did not ensure that resident's catheter needs were met

Licensing Program Analyst (LPA) Tao conducted an unannounced initial complaint visit to the facility regarding the above-mentioned allegations. Upon arrival, LPA met Dawnyell, director and explained the purpose of today’s visit. The investigation consisted of interviews of staff from Staff #1 (S1) through Staff #4 (S4); interviews of residents from resident#2 (R2) through resident #6 (R6); attempted to interview resident #1 (R1); reviews of resident#1 (R1)’s record; and tour of the facility. LPA obtained copies of the staff and resident rosters, and resident #1 (R1)’s records with relevant information. The investigation revealed the following: Regarding the allegation “staff neglect led to resident suffering from multiple UTIs,” it was alleged that resident#1 (R1) had recurrent UTIs in a few weeks due to staff’s negligence. (- continued in LIC 9099 C-) Unsubstantiated LPA Tao attempted to interview resident#1 but all attempts failed. Five (5) out of six (6) residents interviewed could not corroborate the allegation. Resident reviews revealed that staff was not being negligent taking care of residents who has/had UTIs. Four (4) staff interviewed denied the allegation. LPA reviewed R1’s facility record revealed that R1 had UTIs due to having catheter for years and staff had been monitoring resident closely. Therefore, resident who has recurrent UTIs was not due to staff negligent. Regarding the allegation “staff did not seek medical attention for resident in a timely manner,” it was alleged that staff did not send resident#1 (R1) to hospital for medical treatment on a timely basis. LPA attempted to interview resident#1 but all attempts failed. Five (5) out of six (6) residents interviewed could not corroborate the allegation. It revealed that residents received medical treatments as needed on a timely basis. Four (4) staff interviewed denied the allegation. LPA reviewed R1’s facility record revealed that staff had monitored R1’s medical needs closely and provided medical care timely. Therefore, facility staff did not fail to seek medical attention for resident in a timely manner. Regarding the allegation “staff did not ensure that resident's catheter needs were met,” it was alleged that staff failed to change resident#1’s catheter bag nightly. LPA attempted to interview resident#1 but all attempts failed. Five (5) out of six (6) residents interviewed could not corroborate the allegation. Four (4) staff interviewed denied the allegation. LPA reviewed R1’s facility record revealed facility staff was not allowed to change catheter tube and bag because facility is not a skilled nursing facility. Resident’s catheter bag needed to be changed in the hospital. Therefore, staff had met resident's catheter needs while in care. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. 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 allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator and findings were discussed. A copy this report was provided to Administrator at time of visit.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 28-AS-20230703110346

Allegation investigated: 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.

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 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.the state’s words, verbatim · CDSS document, Apr 25, 2023 · control 28-AS-20230417150324

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Apr 11, 2023

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

*****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 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.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 28-AS-20221223120948

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 23, 2023

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: 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.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: 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. 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. Program Clinical Consultants Toni Rivera and Anna Guinto were also present for the visit. LPA met with 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 56 residents in the Assisted Living section and 4 in the Memory Care unit. During the tour today, the following were observed: * 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 and nothing obstructing the walkways. * All doors have signage posted to promote masking and symptom checks. Hallways, common areas, bathrooms have proper COVID-19 signage. LPA recommended for the cough/sneeze signage to be added to the buildings. * Visitors 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. * Facility keeps a binder with current Provider Information Notices (PINs) by the Pitzer South entrance for reference. * There are hand sanitizer stations located by each entry/exiting door. * There is an isolation room (room #2) 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. * All staff and residents (if tolerable) were wearing face masks. * Food supplies of 2 day perishable and at least a week of nonperishable were observed. * Per the Administrator, the housekeepers disinfect high touched surfaces at least 2x per shift. * 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 recommended to have paper towel and soap readily available inside the laundry area. No deficiencies were issued during the visit today. An exit interview was held and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Dec 1, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management visit. LPA met with Director of Assisted Living Dawnyell Varela acting as Director of Memory, Nursing Supervisor Rosie Linarez and Vice President of Health Services Rich Rodas and discussed the purpose of the visit. LPA is following up on Incident Report dated 10-21-22, regarding the unsupervised wandering of Resident #1 (R1). The visit consisted of interviews with Staff #1 (S1), Staff #2 (S2), Witness #1 (W1) and Resident #1 (R1). LPA requested and obtained Dementia Plan of Operation, Dementia training for caregivers, Facility Personnel Roster for 10-21-22, Resident Roster, Resident 1 (R1) File, Personnel files, R1 Physician Report, and written statement by staff. Director of Assisted Living Dawnyell Varela and Nursing Supervisor Rosie Linarez, assisted with tour of memory care cottage (Rauch House) located on the northwest corner of the campus. The Plan of Operation for the 6-bed Rauch House states that the Licensee will advertise dementia care and caregivers in the Rauch House will posses the required training. The Rauch House is encompassed by a 6-foot fence around the backyard with a service gate. The home consists of four (4) bedrooms: 2 private & 2 semi-private; 2 full bath bathrooms, dining area, kitchen, living room, laundry area, an outdoor patio area with furniture to accommodate the residents (including a wander path for leisure walking). The facility is equipped with a SARA System that is tied into the facility staff pagers. LPA observed all walkways to be clear and free of hazards. LPA observed a central entry gate to locked and required a passcode from staff to enter. LPA observed the main entry gate to sound an alarm with a 15 second delay, until the gate opens. *Continued on 809C On October 21, 2022, at approximately 5:55 a.m., S1 was waking up from a nap in her vehicle which was parked on Eight St. S1 noticed something or someone laying in the middle of the road. S1 turned on her car headlights and saw that it was a woman. At approximately 6:10 a.m., male witness (W1) approached the woman and S1 to render assistance. S1 realized that the woman was a resident of the home. W1 attempted to assist R1 back on her feet but, R1 kept falling to her hands and knees after a few steps. At 6:35 a.m., S1 walked into the home to alert S2 that R1 was outside the facility and unsupervised. S2 stated that she was aware and that at 6:26 a.m., she notified Memory Care Director Rosaline Harris of R1 elopement. R1 was taken by paramedics to Pomona Valley Hospital for evaluation. It was reported and confirmed by internal investigation that R1 wandered away from the facility unsupervised for approximately 20 to 30 minutes. As a result, from wandering away unsupervised from the facility, R1 suffered a fractured right wrist due to a fall. Although the facility is equipped with SARA System alarm; it was not noted to be in disrepair on or before 10-21-22, it is unclear how R1 was still able to wander away without detection from staff. LPA was notified during the tour of the facility that 3 cameras with motion sensors have been added. An audible chime/alarm has now been placed on main entry of door. Based upon interviews and information obtained, deficiency cited on LIC 809D. Appeal rights explained and exit interview conducted with Dawnyell Varela.the state’s words, verbatim · CDSS document, Nov 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 8, 2022

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observations, the licensee did not comply witrh the section cited above in that the resident was able to wander away from the facility unsupervised and without detection from staff, which pose/posed a potential health, safety or potential rights to persons in carethe state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: Facility will submit newly updated policy regarding responding to resident alarms and training on how to resond accordingly.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Dawnyell Varela and explained the purpose of today's visit. This is an RCFE - Continuing Care Retirement Community (CCRC). Facility serves elderly residents (age 60 and above). Facility is fire cleared for 252 Ambulatory, 106 Non-Ambulatory, and 96 Bedridden. Facility has an approved Hospice Waiver to retain/accept (10) residents. There currently are (49) residents in assisted-living: (2) hospice, (0) bedridden (0) exception, and (2) receiving home health. LPA also observed the residents during meal time (lunch). The following was inspected and toured: Pitzer (South), Pitzer (North), Pitzer (East), and Pitzer (Friendship Court) which include: resident's studio, 1-bed room and/or 2-bed room apartments, with private bathrooms, living room, dining area, a commercial-size kitchen in the main building, indoor/outdoor activity areas. All residents’ apartments have the required furniture for privacy, comfort, and safety. Bathrooms were observed to be clean and operational (w/grab bars and non-skid surface/mats in place). Hot water temperature tested between 111*F degrees. Required notifications and postings were observed throughout the facility in the different buildings located on bulletin boards and all included: Resident Personal rights, Facility sketch, Visitor policy, complaint procedures, menu and emergency disaster plan. The following was observed/inspected: COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways throughout the facility. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Residents are able to use their private accommodations as isolation rooms as all resident rooms are private and facility also has a designated COVID-19 isolation room that is available to be used for residents that have a shared room, such as couples, if a COVID-19 positive case should arise. Per Administrator Varela, all Residents (Assisted Living and Memory Care) are fully vaccinated. Per Administrator Varela, Staff are vaccinated. However, 1 staff is pending the booster. Staff responsible for direct care and supervision were observed wearing masks. Residents were socially distanced according to local public health guidelines. Residents were observed wearing masks. Facility has an adequate amount of PPE and facility has enough PPE for 6 months. Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc). Restrooms were observed to have sufficient soap, paper towels, hand sanitizer and signs promoting proper hand washing etiquette. Facility has a laundry room that is designated as a COVID-19 laundry room if the facility has a positive case(s). Residents temperature is checked and logged twice a day. Staff temperatures are checked and logged twice a day. Surveillance testing is conducted once a week. Mass testing is conducted weekly if there is a positive case in the facility (includes independent living). All facility staff is FIT Tested. According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time. An exit interview conducted with Administrator Dawnyell Varela and copy of report provided.the state’s words, verbatim · CDSS document, Feb 10, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPA's), Linda Almaraz and Nina Galarza conducted a visit to the above facility for a PRE-LICENSING evaluation for 1 additional building which will be Memory Care. LPA's met with Vice President, Rich Rodas, Director of Memory Care, Rosaline Harris, CEO, Ron Boling, and Ted Morales, Director of Buildings and Grounds. An application was submitted to CCLD for an additional memory care building with a capacity of six (6). The building address is 704 1/2 W. 8th St, which is part of Pilgrim Place Campus. Structure: Facility is a (4) bedroom, (2) bathroom, single-story house. The home has a living room, dining room and large kitchen. There is a large, covered patio area with furniture and shade which is shared with 704 W. 8th St. memory care building. The residents bedrooms are spacious and will easily accommodate the resident's furnishings. Signal system: All exits doors are equipped with a sensor type alarm systems which alerts staff on their pagers. Bedrooms Residents: Bedrooms are approved for non-ambulatory residents. All bedrooms have the required bed(s), chair(s), night stand(s), lamp(s) in addition to overhead lighting. Each resident has a large closet with drawers.. Laundry Room: Laundry room is secured with washer and dryer. Laundry supply is secured and locked separately. Bathrooms: All bathrooms have a working toilet, wash basin, shower. There is one (2) bathrooms in the facility. (Continued on an LIC-9099-C) Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blankets and bedspreads. Adequate supply of linen stored in the laundry room. Emergency Phone Numbers, Exit Plan & Menu: Facility’s telephone system is landline. Numbers posted & readily available for review. Fire Extinguishers located in the dining room, living and hallway. Food Service: Dishes, cups and utensils are stored in the kitchen inspected and in good repair. Food supply adequate for seven (7) days of non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: Electrical & connected. Battery operated & working. Carbon monoxide detector located in the hallway and is operational. Appliances: Stove burners, oven, microwave, washer, and dryer working. There is two (2) refrigerators in the home, a small one is located in the medication room which will be utilized for refrigerated medication and one in the kitchen for food. Freezer is at (0) zero degrees Fahrenheit. The facility is equipped with central air and heating and each residents bedrooms are comfortable in temperature. Water Temperature: Tested at 114.6*F in bathroom #1 and 107.4*F degrees in bathroom #2 . Medications, First-Aid Kit & Book: A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first-aid manual, which are stored in the medication room, available for staff use but inaccessible to residents. (Continued on LIC 9099-C) Residents Records & Staff Files: Applicant will not be handling cash resources of residents, therefore no Surety Bond will be required. Records of staff and residents shall be stored in a locked cabinet. Reading Material, Games, Equipment & Materials: The facility has board games, exercise equipment, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Fire Clearance was approved on 4/14/21. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. An exit interview was conducted and a copy of this report has been furnished to the Licensee Applicant Representative (Rich Rodas). Accordingly, LPA will submit a copy of this Facility Evaluation Report to the Central Applications Unit (CAU) for review. If Licensee Applicant Representative has questions regarding the status of the application, they have been instructed to communicate with their CAU Analyst assigned to process their application.the state’s words, verbatim · CDSS document, Jul 27, 2021