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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603218
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:52:07 PM


Document Has Been Signed on 02/09/2024 04:52 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 IIIFACILITY NUMBER:
198603218
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:380 W BASELINE RDTELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Caregiver-Baltazar ReyesTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on
02/00/2024. LPA was met by Caregiver Baltazar Reyes and explained the purpose of the visit. The facility is licensed to serve six (6six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for two (2).

LPA OBSERVATIONS: The facility is a single-story dwelling located on a main street and consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory device on entry of door to be operational, sliding door and exits.

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 centrally stored medications in kitchen cabinet to be locked during visit. LPA Ramirez observed sharps and knives near kitchen cabinet to be locked during visit. First aid kit was observed in kitchen cabinet. Emergency food supply was stored in kitchen pantry.

Dining Room/Living room/: LPA Ramirez observed plenty of lighting and seating in this area. LPA Ramirez observed several recliners in living room area. One (1) large dining room table with six (6) chairs was observed.

Laundry room: LPA Ramirez observed laundry detergent to be locked during visit.

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

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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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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: 02/09/2024
NARRATIVE
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Resident Rooms 1-4: LPA Ramirez inspected four (4) resident rooms. LPA Ramirez observed all rooms to contain required lighting, furniture, and linen. LPA Ramirez observed auditory device on S6’s bedroom door.

Bathrooms 1-2: bathroom# 1 water temperature measured at 106.2-degree F which is within the required 105F - 120F degrees. LPA Ramirez observed Resident bathroom #2 water temperature was measured at 105.6-degree F which is within the required 105F- 120F. LPA Ramirez observed signs promoting proper hand washing. LPA Ramirez observed grab bars near toilet and showers and no slip coating in showers.

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

Garage: LPA Ramirez observed emergency water in this area.

Emergency Drills: Last documented fire drill wasdrills were conducted on 01/16/2024 and 02/13/2023.

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 the facility. LPA Ramirez reviewed three (3) personnel records. Documented proof of required annual initial training and annual training was observed. Administrator's Certificate for Lea Loaiza was observed with an expiration date of 9/19/2024.

Resident Files: Six (6) resident files and Medications Administration Record (MAR) were reviewed.

Liability Insurance & Infection Control Plan: Licensee could not provide liability insurance. LPA Ramirez observed infection control plan however, infection control plan was not observed to comply with Title 22.




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

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/09/2024 04:52 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning supplies were observed to be accessible in bathroom#1 sink cabinet, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Staff removed cleaning solutions after discovery and placed in secure area. Licensee will re-train staff on above regulation and send proof of re-training by 02/23/2024.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/09/2024 04:52 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

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 observation, Licensee could not provide documentation of liability insurance when requested, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will obtain liability insurance per Title 22 regulations and maintain insurance. Proof of insurance must be submitted via email by 2/16/24.
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, facility is not conducting drills at least quarterly,the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will conduct drills according to above regulation and re-train staff on regulation. Proof of re-training due by 02/16/2024 via email.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5