361880783-9-21-2022-56-AS-RGAR-CJGU3H-20220921151333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880783
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:13:44 PM

Document Has Been Signed on 09/21/2022 03:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	FIL-AM HOME FOR SENIORS IV		FACILITY NUMBER:	361880783
ADMINISTRATOR:	MICLAT, TOBY		FACILITY TYPE:	740
ADDRESS:	359 W LANGSTON STREET		TELEPHONE:	(714) 408-8996
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	6	CENSUS: 3	DATE:	09/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Toby Miclat- Administrator		TIME COMPLETED:	03:22 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Toby Miclat and was granted entry to the facility. At the time of the visit there were three (3) staff, and three (3) residents present. LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Toby Miclat. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, and a symptom check. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the kitchen cabinet. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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 3

Document Has Been Signed on 09/21/2022 03:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: FIL-AM HOME FOR SENIORS IV	FACILITY NUMBER: 361880783
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)

87307. Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by observation, the licensee did not comply with the section cited above by allowing staff to reside and sleep in a hallway closet which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87307 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to vacate the staff, the bed, and their belongings out of the hallway closet. The licensee has agreed to send LPA pictures to show that the bed and staff belongings have been moved out of the hallway closet. POC is due by 9/24/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: FIL-AM HOME FOR SENIORS IV	FACILITY NUMBER: 361880783
	VISIT DATE: 09/21/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During today visit, LPA found that staff is residing and sleeping in the hallway closet. The hallway closet has a bed, staff clothing, staff belongings, and a dresser. The facility will be issued a type B deficiency for using the hallway closet as a staff bedroom which poses a potential health, safety, or personal rights risk to persons in care.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Toby Miclat, along with a copy of the LIC809D form and appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3