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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602527
Report Date: 06/09/2021
Date Signed: 06/10/2021 05:01:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FIL-AM FOR SENIORSFACILITY NUMBER:
198602527
ADMINISTRATOR:CRISS, CRISTINAFACILITY TYPE:
740
ADDRESS:1920 N INDIAN HILL BLVDTELEPHONE:
(562) 547-6833
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Adminstrator, Toby MiclatTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the facility above. LPA met with Administrator Toby Miclat and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is approved.

The facility is a 5 bedroom, 2 bathroom home located in a residential neighborhood. Facility has a main entry point for screening. All 6 residents bedrooms were toured. Each bedroom had required furniture and equipment. All bathrooms were toured and the toilets, hand washing and shower are safe and sanitary. Bathrooms had hand soap. The food in the kitchen was sufficient supply of 2 days perishable and 7 days non-perishable. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records. Carbon monoxide and smoke alarm detectors were tested and working. Water temperature in both bathrooms were within required range of 105-120 degree F.

During medication review, LPA observed resident medications were being transferred 7 days in advance onto a different container with several discrepancies on the quantity administered and left.

An exit Interview was conducted with the Administrator and a hardcopy was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FIL-AM FOR SENIORS
FACILITY NUMBER: 198602527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)


This requirement is not met as evidenced by: During the medication inspection there was several discrepencies on the quantity of each medication. LPA was told by Administrator the facility does an advance 7 day medication set up by transferring medication onto a medication container for each resident. Both Administator and LPA reviewed the medication container and saw 7 days worth medication transferred.
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in 6 out 6 of residents medication which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2021
Plan of Correction
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Administrator will ensure that all medication remains in its original container/pack and is not transferred, effective immediately. Administrator will send LPA a plan of action and a signed written statement stating she has read section 87465, understands it and will abide by it.
Type B
Section Cited
CCR
87465(c)(2)


This requirement is not met as evidenced by: Upon reviewing medication for Residents #1 and #2, LPA observed several descrenpencies on the quanity left and administered for more than 1 medication for each resident. LPA was told by Caregiver Marie residents sometimes refuse the medication. LPA did not see any documentation on refusals and/or record of the physician being contacted in regards to the refusals. LPA was unable to determine medication was given according to the physcians direction.
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above in 2 out of 6 residents medications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2021
Plan of Correction
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Administrator will send to LPA a plan of action addressing the correction of medication being administered. Administrator will provide medication training by a skilled professional, such as a nurse or pharmacist, to staff who dispense medication. Administrator will send proof of training for staff who received training along with topics covered to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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