198602631-1-27-2022-28-AS-LMOA-CB3VF6-20220127152326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602631
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:23:36 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 HOME FOR SENIORS II		FACILITY NUMBER:	198602631
ADMINISTRATOR:	CRISS, CRISTINA		FACILITY TYPE:	740
ADDRESS:	1731 SHENANDOAH DR		TELEPHONE:	(562) 547-6833
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	01/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Rodrigo Celesios - Caregiver		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Rodrigo Celesios and explained the reason for the visit. The Administrator Toby Miclat arrived a few hours after. The physical plant was toured, resident files and medication records were reviewed, staff files were reviewed, and food supply was inspected. Facility is licensed to serve 5 non-ambulatory residents and one bedridden ages 60 and above and may retain two hospice residents. LPA and Caregiver Rodrigo Celesios toured the facility which included the following: 5 resident rooms, 1 caregiver room, 1 resident and 1 staff bathroom, living room, kitchen, dining area, and laundry room. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and both measured at 117 degrees F which is within the required 105 - 120 degrees. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is a cabinet in the hallway with extra clean linen and towels. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is a carbon monoxide in the dining area, and it is properly operating. There are 2 fire extinguishers located in the hallway and caregiver room which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in the laundry room and are inaccessible to residents. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to residents. First Aid kit was fully stocked with current manual and it is kept locked in the resident medication closet in the hallway. (CONTINUED TO LIC 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FIL-AM HOME FOR SENIORS II	FACILITY NUMBER: 198602631
	VISIT DATE: 01/27/2022

NARRATIVE

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Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. A supply of 30-day Personal Protective Equipment (PPE) was observed in the facility. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Resident medications, files, and staff files are centrally stored in a locked closet in the hallway. All six of the resident files and medications were reviewed and no deficiencies were found. Medications are documented properly and given as prescribed. Four staff files were reviewed and a deficiency was found. Staff 1 (S1) and Staff 2 (S2) did not have a health screening in their files.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there is deficiencies observed during the visit (Refer to LIC 809D). Exit interview held and a copy of the report and appeal rights was provided

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 HOME FOR SENIORS II	FACILITY NUMBER: 198602631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. S1 and S2 did not have a health screening with proof of a TB clearance on file.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Facility will submit a copy of the health screening with TB clearances for both staff members by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

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