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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603406
Report Date: 12/29/2020
Date Signed: 12/30/2020 10:51:56 AM

Document Has Been Signed on 12/30/2020 10:51 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
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:FIL-AM HOME FOR SENIORS: LANSING'SFACILITY NUMBER:
198603406
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:1120 W. BRIARCROFT RD.TELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: DATE:
12/29/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:TOBY MICLATTIME COMPLETED:
01:40 PM
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Facility Type: RCFE
Application Type: INITIAL
Capacity: 0006
Census (if any clients in care):

COMP II by CAB successfully completed

Method: Telephone call


COMP II Participant: TOBY MICLAT

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Stefania Fonteno
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2020
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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