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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603218
Report Date: 01/03/2023
Date Signed: 01/03/2023 02:46:50 PM

Substantiated


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
12/28/2022 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221228135040
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: 4DATE:
01/03/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Toby MiclatTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are not following COVID-19 protocols.
Facility staff locked facility front door from the inside.
Facility staff placed a lock on the kitchen door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Caregiver, Marlon Simbajom who allowed entry into the facility. Administrator, Toby Miclat arrived at the facility a short time later, and assisted with the visit.

The investigation consisted of the following: Interview(s) with Administrator, and Staff #1, tour of facility, review of facility sign in sheet, and review of PPE supply. Regarding the allegation that facility staff are not following Covid-19 protocols, LPA observed that staff #1 was wearing an N95 face mask on today's visit, however the mask was not worn correctly. Staff #1 was wearing the mask, with 2 straps hanging under his chin. LPA observed that Administrator was wearing a face mask when she arrived at the facility. LPA also observed facility evaluation report, for annual visit dated 12/29/22, it stated that staff #1 was not wearing a face mask and did not screen visitor upon entry.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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 4
Control Number 28-AS-20221228135040
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: 01/03/2023
NARRATIVE
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Regarding the allegation that facility staff locked facility front door from the inside, Administrator stated that was true. She stated that there was a former resident who would wander, and they kept the door locked, to prevent that resident from leaving the facility. She stated that facility staff have the key to unlock the front door. LPA observed the door was locked, and observed that it could only be opened with a key that staff had. Regarding the allegation that facility staff placed a lock on the kitchen door, Administrator stated that was true. She said that former resident and resident #1 have a habit of going into the kitchen and contaminating the food, by drinking directly out of the milk container, and touching all of the food. She said the facility began to lock the kitchen door(s) in order to prevent the residents from contaminating the food, and from over eating.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Ms. Miclat. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20221228135040
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
HSC
1569.50(a)(3)
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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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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 have been trained, and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.
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This requirement is not being met as evidenced by: LPA observed that staff #1 was not wearing his N95 mask properly on today's visit. And, Staff #1 was not wearing a mask on 12/29/22 visit and did not screen visitor, until prompted by administrator.
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Type B
01/06/2023
Section Cited
CCR
87468.1(a)(6)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
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Administrator will ensure that the front door lock is changed, so that it can be unlocked without the use of a key. Administrator will send proof of correction to LPA by POC due date.
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This requirement is not being met as evidenced by: LPA observed that facility front door, is locked and can only be unlocked with the key that only staff has access to.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20221228135040
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
HSC
87468.1(a(3)
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a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Administrator will ensure that the kitchen doors are no longer locked, and that locks are removed from door(s). Administrator will send proof of correction to LPA by POC due date.
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This requirement is not being met as evidenced by: LPA observed that the kitchen door(s) have locks on them. One door, is a sliding pocket door, that has a hook with a latch. The other door has a lock on the door knob.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4