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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602631
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:32:12 PM

Document Has Been Signed on 12/02/2025 05:32 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 IIFACILITY NUMBER:
198602631
ADMINISTRATOR/
DIRECTOR:		CRISS, CRISTINAFACILITY TYPE:
740
ADDRESS:1731 SHENANDOAH DRTELEPHONE:
(562) 547-6833
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Max Raharuhi, Administrator Assistant & Kevin Ortiz, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:39 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 Maria Heidi Baquiran 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 five (5) non-ambulatory residents and one (1) bedridden only. This facility may retain no more than two (2) hospice residents. There were four (4) residents under hospice care during inspection.

Facility Tour & Observations

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. 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 five (5) resident bedrooms, one (1) restrooms, living room, kitchen, dining area, laundry room, garage, front yard, and backyard. LPA observed five (5) resident bedrooms, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). 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) 115.2°F which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet.

**Continued on LIC809C**

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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 10
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 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 01:23 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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. Four (3) out of four (4) staff files did not contain TB test results or physical examinations, which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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The licensee agrees to ensure all staff obtain TB tests and physical examinations. Proof of completed TB tests and physical exams for all staff will be submitted by the POC 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 01:23 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 as three (3) out of four (4) staff files did not contain documentation of required ongoing/continuing training which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send proof by POC date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 of six (6) residents file did not contain a current physician’s order authorizing the use of bed rails which poses/posed a potential health, safety or personal rights risk to
POC Due Date: 12/23/2025
Plan of Correction
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Licensee to obtain a physicians order for bed rails.
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: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 02:23 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by kitchen cabinet door lock being broken which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2025
Plan of Correction
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Licensee shall ensure that disinfectants, cleaning solutions be locked at all times. Licensee to fix lock on cabinet door.

***POC cleared at the time of visit.***
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 02:51 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 one (1) out of four (4) staff/caregivers did not have proof of first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 03:10 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in two (2) out four (4) residents, medication review revealed there were over the counter medications not prescribed by physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Licensee to obtain a physician’s order for Imodium and Claritin (allergy medication) or discontinue medications and submit by POC due date. Licensee to continue to review PRN policy with residents’ families.
Type B
Section Cited
CCR
87633(a)(1)
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met:

(1) The licensee has received a hospice care waiver from the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above as the facility has a hospice waiver for only two (2) but currently has four (4) residents on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Licensee to ensure they they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase.
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: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 03:20 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have updated re-appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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2
3
4
Licensee to ensure they are updating appraisals as frequently as necessary or once every twelve months. Licensee to submit updated re-appraisals by POC date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FIL-AM HOME FOR SENIORS II
FACILITY NUMBER: 198602631
VISIT DATE: 12/02/2025
NARRATIVE
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Smoke/carbon monoxide detectors were functional; fire extinguisher was located by the front entrance. There were no bodies of water present. 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 were reviewed. Files contained Admissions Agreements, Pre-Placement Appraisals, Consents and Rights Acknowledgments. However, TB test results were missing from the files reviewed, which does not meet Title 22 record keeping requirements. Four (4) residents’ medications were reviewed and two (2) out of four (4) residents had unprescribed PRN’s; medications were observed to be centrally stored in a locked hallway closet. MAR logs were observed to be current.

Disaster Preparedness

Last fire/earthquake drill was conducted on October 19, 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) files were reviewed and included criminal record clearances, two (2) out of four (4) files did not have updated CPR/First Aid training, required annual trainings and three (3) out of (4) did not have TB screenings.

Insurance

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

An exit interview was conducted with Kevin Ortiz Lead Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. Kevin Ortiz Lead Caregiver was advised of the nature of the deficiency, the regulatory basis, and the required Plan of Correction (POC). Mr. Ortiz agreed to submit proof of corrections by the POC due dates specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.

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

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 12/02/2025 05:32 PM - It Cannot Be Edited


Created By: Gabriela Castro On 12/02/2025 at 05:12 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 II
FACILITY NUMBER: 198602631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
(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
1
2
3
4
Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
1
2
3
4
Licensee is to ensure compliance on Communicable Tuberculosis examinations prior to acceptance of a resident. Licensee is to submit proof of TB text by POC date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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