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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603218
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:08:02 AM


Document Has Been Signed on 04/30/2024 11:08 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: 6DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:21 AM
MET WITH:Toby Miclat, Administrator TIME COMPLETED:
11:16 AM
NARRATIVE
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On 12/05/2022, Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit. During this visit LPA met with Acting Administrator Lea Loaiza and explained the purpose of today's visit. LPA conducted a tour of this facility. LPA did not observe any signs of neglect, or abuse, but did observe health and safety risk. LPA cited facility on Case Management report and 809D. LPA also reviewed files for three residents and obtained relevant documentation. LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today.

On 08/08/2023 LPA Alberto Lopez made a subsequent visit to facility and met with Administrator Toby Miclat and discussed the purpose of the visit. LPA took a tour of the living room, dining areas, kitchen, common areas, and random resident rooms. LPA did not observe any signs of neglect, abuse or other immediate health and safety risks. LPA requested copies of staff and resident roster, and interviewed four(4) Staff (S#1-S#4) and six (6)residents (R#1-R#6).

LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2).

04/30/24 - During today’s visit, LPA took a tour of the facility, including random resident rooms, and common areas of the facility.

According to Department interviews, and records reviewed, and observation, The facility was using half rails for resident #1 (1) and #6 (6) without a doctor’s orders which poses an immediate health, safety, or personal rights risk to persons in care. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6 and Chapter 8

Exit interview, a copy of this report and Appeals Rights were provided to the Facility Administrator Toby Miclat

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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 2


Document Has Been Signed on 04/30/2024 11:08 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87608(a)(3)

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87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidence by:
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Administrator will obtain doctor's orders for R1 and will read section 87608 and send a written letter to LPA indicting that Administrator understood the section and how it facility will prevent this from happening again by POC date.
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LPA observed R1 with double half rails and Administrator stated that the facility did not have a doctor’s order for the half bed rails that were used for R1 and R6 bed which poses an immediate health, safety, or personal rights risk to persons in care.
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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: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2