198603218-3-16-2022-28-AS-MVAO-CDMUYP-20220419160016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603218
Report Date: 03/16/2022
Date Signed: 03/16/2022 05:33:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/30/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211230171330

FACILITY NAME:	FIL-AM HOME FOR SENIORS III		FACILITY NUMBER:	198603218
ADMINISTRATOR:	MICLAT, TOBY		FACILITY TYPE:	740
ADDRESS:	380 W BASELINE RD		TELEPHONE:	(714) 408-8996
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Lawton Villanueva, Staff		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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1. Resident developed a bedsore while in care.
2. Resident is left in soiled diaper(s) for an extended period of time.
3. Resident's diapering needs not being met.
4. Resident is being harassed by other resident in care.
5. Resident was pinched by other resident in care.
6. Resident is not being provided activities while in care.
7. Resident's bathing needs not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted the subsequent visit for the allegations listed above. LPA met with Staff, Lawton Villanueva and explained the purpose of the visit. LPA spoke with Administrator, Toby Miclat via telephone.

The investigation consisted of the following:

On 1/4/22, LPA C. Wong initiated the complaint investigation and requested the documents: staff rosters with contact information, all four residents (R1- R4) included LIC601- Identification and Emergency Information, LIC602-Physician Report, LIC622- Centrally Stored Medication Record, LIC 625 - Appraisal Needs and Service Plan and copies of incident reports for Resident #1 (R1). During today’s visit on 3/16/22, LPA Chan interviewed the Administrator, 3 Staff, and 3 Residents. The other resident was not home at time of visit.

(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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 3

Control Number 28-AS-20211230171330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 198603218
	VISIT DATE: 03/16/2022

NARRATIVE

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Regarding allegation - Resident developed a bedsore while care. LPA interviewed the Administrator and 2 Staff who assisted Resident #1 (R1) during the stay at this home. Resident #1 had moved out of the facility on January 2, 2022. According to the interviews, resident had slight redness to the middle buttock area back in December and did not believe it was a bedsore. They stated they repositioned R1 every 2 hours and changed the diaper often. When they discovered the redness, they immediately applied cream to prevent it from getting worse. Per their observation, there was no broken skin in the buttock area, only slight redness. LPA also interviewed the Administrator at the home where R1 is now residing and Administrator stated there was no bedsore when R1 moved into her home. Based on information gathered, there was no evidence to prove R1 developed a bedsore.

Regarding allegations - Resident is left in soiled diaper(s) for an extended period of time and Resident's diapering needs are not being met. The Administrator and Staff interviewed denied these allegations. Staff indicated that they check on residents diapers every 2 hours and would change them as needed. They do not leave residents sitting in soiled diapers due to possible tearing of the skin. They also stated that residents have call bells in the rooms for residents to signal for staff if they need assistance and to have their diaper changed as well. The residents interviewed stated the staff check their diapers often and change them as needed. They do not leave them sitting in soiled diapers.

Regarding allegation - Resident is being harassed by other resident in care. Per the Administrator and Staff, they have not seen any residents harassing one another. They have not seen any residents poke fun or ridicule another resident based on their behavior. Per Staff, they will intervene right away if a situation arises amongst the residents. They receive training on how to handle residents' behaviors the best way possible.
The residents enjoy living here and none of the them are being harassed by others.

Regarding allegation - Resident was pinched by other resident in care. It was alleged that Resident #1 was pinched by the roommate. The Administrator and Staff have not heard of any residents being pinched by another resident. They check on residents often and ask how they are doing. There were no reports from the residents about being pinched. The residents interview denied pinching their roommate or another resident.

(Continue on LIC9099C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211230171330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 198603218
	VISIT DATE: 03/16/2022

NARRATIVE

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Regarding allegation - Resident is not being provided activities while in care. The Administrator and Staff stated they provide activities to residents depending on their mobility. They would take them outside for walks, do exercises, puzzles, and play sports. Per Staff, Resident #1 who was non-ambulatory, was brought outdoors in the wheelchair to get some sun. Staff also tried to conduct arm and leg exercises to increase strength. 2 out of the 3 residents stated the staff would do activities with them.

Regarding allegation - Resident's bathing needs not being met. It was alleged that Resident #1 was only only getting showers every other week and sponge bath daily. Per the Administrator and Staff, the resident was getting bathe twice a week and bed baths daily due to ambulatory status. The residents interviewed stated Staff showers them daily and they feel clean.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Staff. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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