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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603406
Report Date: 01/16/2026
Date Signed: 01/16/2026 03:00:27 PM

Document Has Been Signed on 01/16/2026 03:00 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FIL-AM HOME FOR SENIORS: LANSING'SFACILITY NUMBER:
198603406
ADMINISTRATOR/
DIRECTOR:		MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:1120 W. BRIARCROFT RD.TELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
01/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Max Raharuhi, Asst. Admn. & Toby Miclat, Licensee TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Joann Hernandez, Caregiver and explained the reason for the visit. Max Raharuhi, Administrator Assistant arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older. The approved capacity is six (6) non-ambulatory residents. The facility is approved to retain no more than four (4) residents receiving hospice care.

There were four (4) residents under hospice care during inspection and two (2) residents receiving home health.

Facility Tour & Observations

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Oxygen was observed in use in the facility. Required “Oxygen in Use / No Smoking” signs were posted throughout the facility in visible locations. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is in a residential area and is a one-story home consisting of six (6) resident bedrooms, two (2) restrooms with one being a private restroom, living room/dining area, kitchen, laundry room, garage, front yard, and backyard w/a gated pool. LPA observed six (6) resident bedrooms, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting).

(continued 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/16/2026 03:00 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/16/2026 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in one (1) out R5 of six residents (6) did not have an admissions agreement on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee will obtain an Admissions Agreement for R5 by POC due date. Moving forward licensee will ensure to obtain Admissions Agreement upon admission.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in two (2) out of six (6) residents R5 and R6 had an incomplete or no pre-appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee will obtain pre-appraisals for R5 and R6 by POC due date. Moving forward licensee will ensure to obtain pre-appraisals upon admission.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/16/2026 03:00 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/16/2026 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in three (3) out of six (6) residents R3, R5 and R6 did not have proof of TB in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee will submit proof of physical exam and TB test for staf R3, R5 and R6 by POC due date. Licensee will ensure to obtain physical and TB test upon prior to admission of resident.
Type B
Section Cited
CCR
87411(c)(1)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in three (3) out of four (4) staff did not have proof of first aid in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee to submit proof of first aid for S1,S2 and S3 by POC due date. Licensee to ensure staff maintain a valid and current first aid certificate on file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FIL-AM HOME FOR SENIORS: LANSING'S
FACILITY NUMBER: 198603406
VISIT DATE: 01/16/2026
NARRATIVE
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Cleaning supplies and toxic substances were accessible to residents in a kitchen cabinet under sink. Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 105.2°F and bathroom (2)105.3 which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet. Smoke/carbon monoxide detectors were functional; fire extinguisher available by front entrance and dining room area. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed.

Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer.

Health-Related Services & Records

Six (6) resident files (R1–R6) were reviewed. All six (6) files were missing Annual Appraisals. Five (5) residents had current Admission Agreements; however, R5 did not have an Admission Agreement on file. Pre-Placement Appraisals were complete for four (4) residents; R5 and R6 had incomplete or missing Pre-Placement Appraisals. Consents, Needs/Service Plans, and Physician’s Reports documenting TB clearance and ambulatory status were present for three (3) residents. Residents R3, R5, and R6 did not have TB test results on file; additionally, R5 did not have a Physician’s Report. Resident Rights acknowledgments were present for all residents. Three (3) residents’ medications were reviewed and observed to be centrally stored in a locked kitchen cabinet. Medication Administration Records (MARs) were current.

Disaster Preparedness

Last fire/earthquake drill was conducted on November 26, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted on kitchen bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated.

Personnel Records & Training

Four (4) staff files were reviewed and included criminal record clearances. CPR/First Aid certificates were missing for two (2) staff members (S1 and S3). TB screenings were missing for three (3) staff members (S2, S3, and S4). Required training documentation was reviewed and present.

Insurance

Liability insurance was in compliance with an expiration date of April 5, 2026.

An exit interview was conducted with Toby Miclat, Administrator. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C and Appeal Rights was provided via email.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
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