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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603218
Report Date: 12/29/2022
Date Signed: 12/30/2022 08:41:31 AM


Document Has Been Signed on 12/30/2022 08:41 AM - 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 IIIFACILITY NUMBER:
198603218
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:380 W BASELINE RDTELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 3DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Administrator Toby MiclatTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Marlon Sambajon and explained the reason for the visit. LPA was later met by Administrator Toby Miclat. Physical Plant was toured, sample record of medications was reviewed, and food supply was inspected. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 years old and a Hospice waiver for two (2) residents. The facility is located on a main street with an open yard.

LPA observed the following:

· Staff was not wearing a face mask when LPA was greeted at the door. Staff did not screen LPA until Caregiver Sambajon called Administrator Miclat and was prompted to screen LPA. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.

· The facility consists of four (4) client bedrooms, living room, dining room, kitchen, TV room, laundry room, one (1) shared resident/staff bathroom, one (1) client bathroom, one (1) staff quarters, attached garage. 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 back patio. Passageways and exits are free of obstruction.

· Shared resident/staff bathroom# 1 water temperature measured at 116.0 F which is within the required 105F - 120F degrees. Light was not working at the time of the visit. Toilet paper was not observed in shared/resident bathroom#1. Sink and bathtub in shared/resident bathroom#1 was dirty with soap residue and hair. Resident bathroom #2 water temperature was measured at 121.6F which is not within the required 105F-120 degrees. Light in resident bathroom#2 was not working during the visit. Paper towels and toilet paper were not present in resident bathroom#2.

· No night-light was observed in hallway leading to resident bathroom#2.

CONT ON 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11


Document Has Been Signed on 12/30/2022 08:41 AM - 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,water temperature in resident bathroom#2 was measured at 121.6 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Administrator/ Licensee will maintain a water temperature log and staff will document water temperature every 24hrs for the next 3 calendar days. Administrator/ Licensee will send proof of log and first water temperature reading by POC due date and final log with temperature reading by 01/02/2023.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medication for Resident #2 (R2) contained Acetaminophen that was not prescribed by a physican but was located in R2's medication storage box and client did not take medication as prescribed on 12/20/22, 12/21/22, 12/25/22 and 12/26/22, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administrator/ Licensee will ensure resident takes medication as prescribed by a physican. Administrator/ Licensee will retrain staff on medication procedure and provide proof of training completeion. Administrator/ Licensee removed unprescribed medication while LPA was present.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 11


Document Has Been Signed on 12/30/2022 08:41 AM - 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, shared/resident bathroom#1 light was not working at the time of the visit. Sink and bath tub in shared/resident bathroom#1 was dirty with soap residue and hair, light in resident bathroom#2 was not working during the visit, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administrator/Licensee will replace light bulbs in both bathrooms, clean sink and tub in shared/resident bathroom#1. Photo proof will be submitted.
Type B
Section Cited
CCR
87307(a)(3)(D)
Personal Accommodations and Services
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,toliet paper was not observed in shared/resident bathroom#1, paper towels and toilet paper were not present in resident bathroom#2, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Administrator/licensee will keep bathrooms stocked with toilet paper and soap. Administrator/licensee corrected while LPA was present.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 12/30/2022 08:41 AM - 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, no nightlight was observed in hallway leading to resident bathroom#2, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Administrator/Licensee will place a nightlight in hallway and send photo proof to LPA. Administrator/Licensee corrected while LPA was present.
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 observation, Administrator/Licensee could not provide such proof and stated liability insurance was expired, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administartor/Licensee will provide current proof of liability insurance.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11


Document Has Been Signed on 12/30/2022 08:41 AM - 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,staff 2 (S2) was not associated with the facility, administrator/licensee was asked by this department to associate S2 on 12/07/2022 but did not comply, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administrator/Licensee will associate staff 2 (S2) on Guardian and provide LPA with proof.
Type B
Section Cited
CCR
87412(a)(4)
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: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, staff1 (S1) was missing social security information on personnel records and copy of drivers license or birth certificate, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administraor/Licensee provided LPA with an email of S1's out of country passport.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 11


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 III
FACILITY NUMBER: 198603218
VISIT DATE: 12/29/2022
NARRATIVE
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  • Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon monoxide detectors are located throughout the home. There is a fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked in the laundry room and are inaccessible to residents. Required grab bars and skid mats were observed in the shower and near the toilet.

· Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed.

· (3) out of the (3) resident medications were reviewed. Medications are centrally stored in a cabinet located in the kitchen.

· LPA reviewed four (4) staff files and discovered Staff1 (S1) Personnel file was missing a copy of Drivers License or birth certificate. LPA also discovered Staff 2 (S2) was not associated with the facility and staff has been actively working in the facility.

· LPA did not observe enough PPE. Administrator Miclat requested additional PPE via email while LPA was conducting visit.

· Fire drill was conducted on 05/19/22.

Deficiencies cited, please see 809D for details. At the time of visit no other deficiencies were observed.


Exit interview done with Administrator Toby Miclat and copy of report and appeal rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 11 of 11