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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602631
Report Date: 11/30/2023
Date Signed: 11/30/2023 06:26:06 PM


Document Has Been Signed on 11/30/2023 06:26 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 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: 5DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:RODRIGO CELESIOS CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/30/2023.
LPA was met by Caregiver Rodrigo Celesios and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which five (5) may be non-ambulatory.

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of five (5) resident bedrooms, one (1) staff bedroom, one (1) resident bathroom, one (1) staff bathroom, kitchen, dining room, living room, front yard, and backyard.

Front Yard: Front yard is well maintained, and no hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 119.3 degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 79 degree F.

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

See 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 11/30/2023 06:26 PM - 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
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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were observed in 2 different trays on top of R2's nightstand, the licensee did not comply with the section cited above in 1 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will remove medications from R2's room and centrally store. Licensee will re-train staff on medication safe keeping and send proof of re-training by 12/14/23. Proof must be submitted via email.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 06:26 PM - 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
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: 11/30/2023

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 record review, licensee did not provide proof of liability insurance, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitor sand which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee will maintain liability insurance as required. Must send proof via email by 12/14/23.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee could not provide documented proof of quarterly drills, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee will conduct quarterly drills and maintain log according to Title 22. Proof of documented drill must be emailed by 12/14/23.
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: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 06:26 PM - 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
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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R3 did not have annual medical assessment, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee will submit proof of recent medical assessment and ensure it is done annually for residents with dementia or if change of condition is observed.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


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 HOME FOR SENIORS II
FACILITY NUMBER: 198602631
VISIT DATE: 11/30/2023
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Resident Rooms 1 - 5: LPA Ramirez inspected five (5) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed proper signage indicating the use of oxygen in two (2) out of the five (5) bedrooms. LPA Ramirez medications prescribed for R2 in two different trays on top of R2’s nightstand. Per record review, R2 may not administer medication or store medication.

Bathroom: Water temperature in bathroom was within 105-120 degree F. LPA observed non-slip mats in shower and grab bars near toilet.

Backyard: No hazards were observed. Plenty of shade and seating was observed.

Centrally Stored Medications: Medications were observed to be stored in facility hallway closet and inaccessible to five (5) out of five (5) residents in care.

Emergency Drills: Staff could not provide documented proof if emergency drills conducted.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: 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 five (5) staff. Documented proof of required annual training was not observed.

Resident Files: Five (5) resident files were reviewed. LPA did not observe required annual physician’s report for R2.

Liability Insurance & Infection Control Plan: Licensee could not furnish proof of liability insurance during visit. LPA Ramirez observed updated infection control plan.



Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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