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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602527
Report Date: 04/29/2024
Date Signed: 04/29/2024 04:28:15 PM


Document Has Been Signed on 04/29/2024 04:28 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: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: 4DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Administrator Lea LoaizaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/29/2024. LPA was met by Caregiver Valentino Delgado and explained the purpose of the visit. Administrator Michelle Aguirre arrived shortly after to assist with the visit. Facility is licensed to residents 60 years old and above. The facility is approved for two (2) ambulatory and four (4) non-ambulatory, of which one (1) may be bedridden. The facility may retain two (2) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), copy of liability insurance and updated Infection Control plan.

LPA OBSERVATIONS: The facility is a single-story building with five (5) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, one (1) staff bathroom, kitchen, dining room, living room, den/tv room, utility/laundry room, front yard, backyard.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables.

Dining Room/Living room/Den/TV room: Dining room was observed to be clean and contained table and 4 chairs. Living room area has plenty of seating for residents and guests. Den/Tv room was observed to be clean and contained plenty of seating. LPA Ramirez three (3) residents sitting in this area during inspection.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 3: All but one resident bedroom is shared. All contained the required furnishings, linens and were observed to be clean.

See 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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: FIL-AM FOR SENIORS
FACILITY NUMBER: 198602527
VISIT DATE: 04/29/2024
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Centrally Stored Medications: Was observed to inaccessible to four (4) out of four (4) residents in care. Medications are stored in facility medications cabinet, which is in facility utility room/laundry room.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. LPA Ramirez observed a First Aid kit in facility utility room.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Lea Loaiza with an expiration date of 09/19/2024. First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed for two (2) out of three (3) personnel records observed.

Resident Records: Four (4) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



No deficiencies were cited during this inspection. Exit interview was conducted and a copy if this report was provided via email due to printer issues.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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