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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603406
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:46:29 PM


Document Has Been Signed on 01/12/2024 04:46 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: 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: 6DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lea ChavezTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver Adora Capa and the facility administrator Lea Chavez arrived shortly after. The facility is licensed for 6 residents with age range 60 and over. 6 Non-ambulatory and hospice waiver for 4. Currently, the facility has four hospice waiver residents, no home health, one on oxygen and no bedridden residents.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control: Infection Control Practices and Personal Protective Equipment (PPE) supplies were observed. Facility Staff still practice hand washing and wear mask in the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirement: The facility has a Dementia Waiver in place. A Hospice Waiver for 4 residents is approved. All resident in the facility is non-ambulatory which is under the fire clearance approval. The facility does not have the actual liability insurance policy and they only have the quote for the liability insurance.

Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, dining area, 6 residents bedroom, 4 bathrooms, laundry room, pantry room and an attached garage. LPA inspected the resident room and each resident room has one bed, one chair, night stand, required furniture and beddings and sufficient lighting and closet space.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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: LANSING'S
FACILITY NUMBER: 198603406
VISIT DATE: 01/12/2024
NARRATIVE
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LPA inspected the bathrooms, each bathroom is clean, sanitary and in a good working condition. Each bathroom has the required grab bar and non-skid mat. The hot water in all resident bathroom are tested between 110.8 and 114 degrees F. which is within the Title 22 regulation. The appliances in the kitchen and living room are working well. The sharp knives are stored and locked in the kitchen cabinet. All the cleaning supplies and chemicals are stored and locked in the garage. The extra linen and towels are stored in the cabinet near the residents room. LPA inspected the carbon monoxide detectors and smoke detectors and they are located in each bedroom and common area and they are all working well. The facility has a pool with water in the backyard. The pool water was clean and pool is surrounded by a locked gated. The passageway, walkway and patio are free of obstruction.

Staffing: The facility has sufficient staffing in the facility. The facility has at least one person to have updated First Aid and CPR training certificate.

Personnel Records-Training Information: All the staff work in the facility are over 18 yeas old and background checked and associated with the facility. All the staff file has the required documents include: health screening, TB test result, updated First Aid Certificate and required training hours. The administrator is Toby Miclat and her administrator certificate was expired on 10/12/2023 and currently the certificate is pending with CCL system since 11/28/23.

Resident's right/Information: The complaint poster from LTCO and CCL are placed on the wall near the entrance door which included the resident personal right and theft and loss policy. The facility also has internet service which provide at least one internet access device such as computer or smart phone..etc for video conferencing with resident's family.

Planned Activities: The facility has a sufficient space to accommodate both indoor and outdoor activities.

Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable food in the facility. Currently there's no resident is on a modified diet that prescribed by the doctor. All the food in the facility are stored properly.

Incidental Medical and Dental: LPA reviewed six residents' medication. R1's daily medication for Vitamin D3 and Omerprazole was not listed on the MARs and not sure if resident was taking the medication. The medication in the facility is centrally stored and locked in the kitchen cabinet. LPA also inspected the First Aid Kit in the facility and they have all the required supplies and updated Manual and stored and locked in the kitchen cabinet.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: LANSING'S
FACILITY NUMBER: 198603406
VISIT DATE: 01/12/2024
NARRATIVE
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Resident's Record-Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, medical consent, and medication records. ***A total of 1 Dementia resident (R1) had Physician Report's older than 12 months. All the residents admission agreement is print double side of the paper.

Disaster Preparedness: The updated Emergency and Disaster Plan LIC 610E is in place and posted on the wall. The facility did not conduct any emergency disaster drill last year. Resident's appraisal and Needs services plans are part of Emergency training.

Residents with Special Health Needs: Four (4) residents receive hospice care. Half and Full bed rails for mobility assistance were observed in residents' rooms. LPA observed one resident (R2) has no doctor order for the half bed rail. Individual Service Plans and appraisals are on file. No Residents have prohibited health condition.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Lea Chavez. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/12/2024 04:46 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: LANSING'S
FACILITY NUMBER: 198603406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record reviewed, LPA observed Resident#1's daily medication Vitamin D3 (50mcg once daily) and omerprazole (20mg one day before meal) was not listed on the MARs and staff not sure if the resident take the medication or not
POC Due Date: 01/13/2024
Plan of Correction
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Administrator will ensure the medication once ordered by physician and the medication is given according to the physician direction and Administrator will retrain the staff for medication and will send the staff training log by POC due date.
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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/12/2024 04:46 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: LANSING'S
FACILITY NUMBER: 198603406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

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 record review, LPA did not observe the actual liabiltiy insurance policy in place and the facility only has the quote which posed a potentil risk to resident in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will ensure the liabitliy insurnace policy is in place and administrator will submit the copy of actual insurance policy by POC due date.
Type B
Section Cited
CCR
87507(a)(1)(A)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed all residents' admission agreement was not on one side of the paper only. They were all on double side which post a potential risk to residnet in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will ensure all the admission agreement print shall appear on one side of the paper only and will update all residents' agreement and send it to LPA by POC due date.
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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 01/12/2024 04:46 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: LANSING'S
FACILITY NUMBER: 198603406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, LPA did not observe any emergency drill was conducted in the past year and staff admitted they did not conduct any fire drill last year which pose a potential risk to residents in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator will ensure the facility shall conduct a drill at least quarterly for each shift. Administrator will conduct a fire/emergency drill with staff and residents and send the copy of the recent drill report to LPA by POC due date.
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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6