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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602631
Report Date: 02/02/2023
Date Signed: 02/02/2023 10:11:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230126120644
FACILITY NAME:FIL-AM HOME FOR SENIORS IIFACILITY NUMBER:
198602631
ADMINISTRATOR:CRISS, CRISTINAFACILITY TYPE:
740
ADDRESS:1731 SHENANDOAH DRTELEPHONE:
(562) 547-6833
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rodrigo Celesios/S-1 and Toby Miclat (Administrator)TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff are not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day visit to investigate the above allegation. LPA was allowed entry by Rodrigo Celesios/S-1. Toby Miclat (Administrator) arrived at approximately 9:12 A.M.. LPA explained the purpose of today’s visit. The investigation consisted of the following: LPA interviewed S-1 and Facility Administrator and obtained a copy of the Staff and Resident Rosters.

Allegation: Staff not following COVID-19 protocols. During this investigation, upon entry LPA observed Staff #2 (S-2) not wearing a mask. LPA observed S-2 obtain an N-95 mask shortly after LPA's arrival, however, S-2, was not wearing the N-95 mask correctly as (1) mask strap was hanging under S-2's chin.

Based on observation, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Health and Safety Code Title 22, Division 6 and Article 3 are being cited on the attached LIC 9099D. An exit Interview was conducted, appeal rights and a copy of this report was provided to Toby Miclat.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230126120644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME FOR SENIORS II
FACILITY NUMBER: 198602631
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited
CCR
87470(c)(1)(F)
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Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F)Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned as
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Administrator will ensure that facility is following California Dept of Public Health and CCLD requirements. Administrator will provide a written statement stating that staff will be retrained, and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.
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evidenced by safe and effective job performance. This standard is not met as evidence by: LPA observed Staff #2 (S-2) not wearing a mask. LPA observed S-2 obtain an N-95 mask shortly after LPA's arrival, however, S-2, was not wearing the N-95 mask correctly as (1) mask strap was hanging under S-2's chin.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2