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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602527
Report Date: 06/20/2023
Date Signed: 06/21/2023 08:50:55 AM


Document Has Been Signed on 06/21/2023 08:50 AM - It Cannot Be Edited

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:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator Toby MiclatTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. LPA met with Administrator Toby Miclat and the purpose of the visit was discussed.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: (2) living rooms, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (5) resident rooms, (1) staff room , (2) bathrooms for residents; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage, Laundry, office/resting space for staff. The residence is equipped with central air and heating. Adequate accommodations observed throughout facility. Facility observed to be clean of obstruction and debris. Bedrooms #1-#5 for resident use are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, beds for each resident, and closet space. Bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Medications are stored, locked and inaccessible to residents in care. Required linen/supplies observed. Facility has a working phone landline. Fire Extinguisher observed fully charged and up to date. The hot water temperature was measured within title 22 regulations. The food supply in the kitchen and pantry has at least two days perishable and seven days non perishable food. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. All appliances observed operational. Toxins and sharps observed to be Locked/stored for staff use only. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations and Disaster plan is maintained at the facility. RECORD REVIEW: LPA reviewed Six (6) resident files, Six (6) residents medications, and three (3) staff files.

Inspection tool completed. Per Title 22 regulations, deficiency is being cited in 809-D page.

Exit interview conducted and a copy of this report and appeal rights were discussed and provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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Document Has Been Signed on 06/21/2023 08:50 AM - It Cannot Be Edited

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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as a current active Liability Insurance Coverage was not provided to LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee to provide Licensing proof of Liability Insurance coverage for the faciltiy by POC Due date. Licensee to contact LPA if time extension is needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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