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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880783
Report Date: 08/06/2021
Date Signed: 08/06/2021 01:25:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FIL-AM HOME FOR SENIORS IVFACILITY NUMBER:
361880783
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:359 W LANGSTON STREETTELEPHONE:
(714) 408-8996
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Toby MiclatTIME COMPLETED:
01:35 PM
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Licensing Program Analysts (LPAs) Melody Brown and Natalie Gayoso made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPAs were greeted and temperatures taken at the door by caregiver Joyce Remigio. Administrator Toby Miclat was at the facility for inspection and LPAs explained the purpose of today's visit. Administrator accompanied LPAs on the tour of the inside and outside of the facility.

During today's visit, LPAs made observations pertaining to the facilities infection control measures. LPAs assert proper signage throughout the facility, with sufficient hygiene supplies and sufficient cleaning and disinfecting provisions. The facility has a 30 day supply of Personal Protective Equipment (PPE) and a 30 days supply of resident medications. The facility has a designated infection control lead person who has been tasked with tracking all Covid-19 cases and/or suspected cases, and staff trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for Covid-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify resident's Physicians and all emergency agencies in the event of any Covid-19 related and/or suspected illness.

An exit interview was conducted and a copy of this report was provided to Administrator Toby Miclat.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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