Pilgrim Place in Claremont

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Dawnyell Varela - Director/Administrator and explained the purpose for today’s visit. The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (58) residents in assisted living, two (2) in memory care, and two hundred and fifty-one (251) residents in Independent Living. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, Care of Bedridden Residents Plan and training, and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, a total of 10 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that are operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. (Continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 6 staff files with no issues observed. Administrator/Director Dawnyell Varela has a valid Administrator certificate that expires 4/2026. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 6 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 11/20/25. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management visit for the purpose of reviewing the expansion of an Independent Living Unit (single-family home), which will be used for independent living residents only. LPA met with Todd Barretta, Chief Financial Officer and Gisele Tackoor, Director of Admissions and discussed the purpose of the visit. A fire clearance approving the requested expansion was granted by the local fire authority on 10/29/2025 address 722 W. 8th Street Claremont, CA 91711. LPA toured the facility with Todd Barretta and Gisele Tackoor. The facility consists of four (4) bedrooms and two (2) bathrooms. The single-family home was observed to be clean, orderly, and in good repair at the time of the visit. Bathrooms were equipped with functioning toilets, wash basins, and showers, and were observed to be sanitary and in good condition. Smoke detectors and carbon monoxide detectors were observed to be operational. Common areas, hallways, and walkways were free of obstructions. No deficiencies were observed during today’s visit. An exit interview was conducted with Todd Barretta, Chief Financial Officer , and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent required annual inspection on 01/02/2025. LPA Ramirez conducted initial required annual inspection on 12/05/2024. LPA met with Dawnyell Varela- Director of Assisted Living and discussed the purpose of today’s visit. The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (55) residents in assisted living and nine (9) in memory care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (55) residents in assisted living and nine(9) in memory care. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for five (5) out of the six (6) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6) out of the six (6) personnel records reviewed. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez reviewed food handler certificates for kitchen staff. Staffing: Administrator Certificate for Richard Rodas expires on 6/15/2026. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. SEE 809-C. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for Resident #1 (R-1) through Resident #8 (R-8). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No violations were observed during this annual inspection. Exit interview was conducted. A copy of this report will be provided vial email.the state’s words, verbatim · CDSS document, Jan 2, 2025

Allegation investigated: Staff are storing spoiled food at the facility. Staff did not ensure that the facility refrigerator was repaired.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 12/24/2024 regarding the above allegations. LPA was greeted by Dawnyell Varela- Director of Assisted Living and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 4 interviews (S1 – S4), Resident Interviews# 1-3 (R1-R3), work orders for walk-in refrigerator#1, email correspondence in regards to walk-in refrigerator #1, and physical plant tour. See 9099-C. Unsubstantiated The investigation revealed the following. Regarding Allegation: Staff are storing spoiled food at the facility – On 12/24/2024, around 9:15 am, LPA Ramirez toured Abernathy kitchen and Health Services Center (HSC) kitchen. Per staff interviews, Abernathy kitchen provides meals for the residents in assisted living and independent living. HSC kitchen provides meals for memory care residents and skilled nursing. During tour of both kitchens, LPA Ramirez did not observe perishables foods to be spoiled. Perishables stored in facility walk-in refrigerators were observed to have labels with dates indicating “use by date”. All walk-in refrigerators and walk-in freezers storing perishable foods were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F (4 degree C). Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) out of the three (3) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not ensure that the facility refrigerator was repaired- During tour of HSC kitchen, LPA Ramirez observed walk-in refrigerator#1 to be locked and inaccessible. Staff opened refrigerator upon request and LPA Ramirez observed the refrigerator to be in empty. Staff interviewed collaborated the walk-in refrigerator in HSC kitchen has been in disrepair for weeks, but the facility placed a work order for the repair as soon as staff observed a change in temperature and is awaiting a replacement unit and budget approval. Staff interviewed revealed all perishable foods that were stored in this walk-in refrigerator, were immediately moved to another walk-in refrigerator in HSC kitchen. LPA Ramirez reviewed several invoices indicating the facility’s continued attempts to repair walk-in refrigerator#1 in HSC kitchen. Records reviewed, showed initial repairs were made however, additional parts were required to complete the repair. LPA Ramirez reviewed email correspondence by maintenance staff submitting work orders for walk-in refrigerator#1, attempts to repair walk-in refrigerator#1 and quotes to replace walk-in refrigerator#1 in HSC kitchen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were observed during this investigation complaint. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Dec 24, 2024 · control 28-AS-20241218141114

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Dawnyell Varela- Director of Assisted Living and discussed the purpose of today’s visit. The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (55) residents in assisted living and seven (7) in memory care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) rooms; of which five (5) in assisted living (Pitzer Lodge) and three (3) in memory care (Rauch Memory Care Homes). All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed evacuation chairs in stairways. 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. See 809-C for continuation. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed a calendar for December of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez emergency food supply. Residents with Special Needs: LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return to conduct subsequent annual inspection, at a later time. No deficiencies were cited at this time. Exit interview was conducted with Dawnyell Varela. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Facility kitchen is not kept free from rats and other vermin.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Dawnyell Varela (Director of Assisted Living) and explained the reason for the visit. The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Director of Assisted Living, Staff 1 - Staff 13 (S1 - S13), and Resident 1 - Resident 5 (R1 - R5). LPA toured the Abernathy kitchen, skilled nursing kitchen and the assisted living kitchen. LPA reviewed pest control service logs dating back to May 2024. Regarding the allegation "facility kitchen is not kept free from rats and other vermin", it is alleged that there is a rat infestation in the Abernathy kitchen. Director of Assisted Living stated that to her knowledge there is no rat infestation. She also stated that Abernathy kitchen is part of the independent living section, but all food for assisted living and memory care is cooked either at the Abernathy kitchen or in the skilled nursing kitchen. (Continued to LIC 9099-C) Unsubstantiated The assisted living kitchen is too small and this is why they use the other two kitchens to cook the food and the food is transported to the assisted living kitchen in hot boxes to serve the assisted living residents. LPA interviewed 6 staff working in the Abernathy kitchen, 4 staff working in the skilled nursing kitchen, and 2 staff working in the assisted living kitchen, and they all denied the allegation. LPA also interviewed a staff from Building and Grounds whom stated that Commercial Quality Pest Control comes every Monday to provide preventive measure services throughout the entire property and there has been no reports of a rat infestation. LPA reviewed the pest control service logs dating back to May 2024 and there is no report stating that there is a rat infestation. Residents interviewed could not corroborate the allegation. LPA toured all 3 kitchens on the property and did not observe any rats or rat droppings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jul 16, 2024 · control 28-AS-20240708142211

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 01/23/24. LPA met with Dawnyell Varela (Director) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the following domains: Staffing: There is sufficient staffing at the facility. Administrator Certificate for Richard Rodas expires 06/15/24 (6041259740). Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA reviewed personnel records for eight (8) personnel. Pertinent staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training including required initial and annual training. Staff#2 (S2) was short 2 hours of Dementia training. LPA Ramirez will issue Technical Violation. Resident Rights-Information: Resident rights are posted and included in Resident files. Let-Us-No poster posted. LTCO poster posted. Resident Records: LPA reviewed six (6) resident records. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) Technical Violation is being cited today. Exit interview is conducted with Dawnyell Varela. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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. * 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.the state’s words, verbatim · CDSS document, Jan 23, 2024

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