<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602631
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:06:13 PM

Document Has Been Signed on 01/15/2026 04:06 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: 4DATE:
01/15/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:34 PM
MET WITH:Kevin Ortiz, Lead Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:30 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) Gabriela Castro conducted an unannounced Case Management visit to address deficiencies related to the failure to correct cited deficiencies. LPA was greeted by Kevin Ortiz, Lead Caregiver and discussed the purpose of the visit.

On December 2, 2025, Licensing Program Analyst (LPA) Gabriela Castro conducted an Annual Inspection and cited deficiencies with a Plan of Correction (POC) due by December 23, 2025. As of the date of the follow-up visit, the deficiencies remained uncorrected.

The following deficiencies were cited:

CCR-87411(f)- 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 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.

Plan of Correction

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.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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 8
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)
Page: 2 of 8
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: 01/15/2026
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
HSC -1569.625(b)(2)- (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.

Plan of Correction

Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send proof by POC date.

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.

Plan of Correction

Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date.

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.

Plan of Correction

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.

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.

Plan of Correction

Licensee to ensure they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase.

(continued on 809C)

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

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 01/15/2026
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
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.

Plan of Correction

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.

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.

Plan of Correction

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.

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. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

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

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/15/2026 04:06 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/15/2026 at 02:12 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
87411(f)

1
2
3
4
5
6
7
All personnel, including the licensee and administrator, shall be in good health, and physically capable of performing assigned tasks .... shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requiment is not met as evidenced by:
Based on record review, the licensee did not comply with the cited section. Three (3) of four (4) staff files lacked TB test results and/or physical examinations, posing a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
01/16/2026
Section Cited
HSC1569.625(b)(2)

1
2
3
4
5
6
7
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...
1
2
3
4
5
6
7
Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send of proof of training by POC date.
8
9
10
11
12
13
14
 This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requiment is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as three (3) of four (4) staff files lacked required ongoing training documentation, posing a potential health and safety risk to persons in care
8
9
10
11
12
13
14
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: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/15/2026 04:06 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/15/2026 at 02:45 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
87411(c)(1)

1
2
3
4
5
6
7
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
1
2
3
4
5
6
7
Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as one (1) of four (4) staff lacked proof of first aid certification, posing a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
01/16/2026
Section Cited
CCR87465(e)

1
2
3
4
5
6
7
(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...
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the cited section, as two (2) of four (4) residents had over-the-counter medications without physician orders, posing a potential health risk to persons in care.
8
9
10
11
12
13
14
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: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/15/2026 04:06 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/15/2026 at 02:57 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
87633(a)(1)

1
2
3
4
5
6
7
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician... who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services...
1
2
3
4
5
6
7
Licensee to ensure they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase.
8
9
10
11
12
13
14
(1) The licensee has received a hospice care waiver from the department.
This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, facility exceeded its hospice waiver capacity (2 approved; 4 on hospice), posing a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
01/16/2026
Section Cited
CCR87463(a)

1
2
3
4
5
6
7
(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.. keep the appraisal accurate.
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
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.
8
9
10
11
12
13
14
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: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/15/2026 04:06 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/15/2026 at 03:09 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
87458(c)(1)(A)

1
2
3
4
5
6
7
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..
(A) Communicable tuberculosis.

1
2
3
4
5
6
7
Licensee is to ensure compliance on Communicable Tuberculosis examinations prior to acceptance of a resident. Licensee is to submit proof of TB test by POC date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: 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.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 8 of 8