198602631-1-21-2026-28-AS-GCAO-DQK2WT-20260121164604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602631
Report Date: 01/21/2026
Date Signed: 01/21/2026 04:46:31 PM

Document Has Been Signed on 01/21/2026 04:46 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 II		FACILITY NUMBER:	198602631
ADMINISTRATOR/ DIRECTOR:	CRISS, CRISTINA		FACILITY TYPE:	740
ADDRESS:	1731 SHENANDOAH DR		TELEPHONE:	(562) 547-6833
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 4	DATE:	01/21/2026
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Kevin Baas, Lead Caregiver		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Plan of Correction (POC) Case Management visit to address deficiencies related to the facility’s failure to correct previously cited deficiencies. LPA was greeted by Kevin Baas, Lead Caregiver and discussed the purpose of the visit. LPA spoke with Licensee Toby Miclat via phone in detail.

On January 15, 2026, LPA conducted a Case Management visit to follow up on deficiencies cited during the Annual Inspection, for which a Plan of Correction (POC) was due by December 23, 2025. During that visit, the deficiencies remained uncorrected, and the deficiencies were re-issued with a new POC due date of January 16, 2026. As of the date of this follow-up visit, the deficiencies remained uncorrected.

The following deficiencies were cited:

CCR 87411(f)- 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 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.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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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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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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: 01/21/2026

NARRATIVE

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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. (POC Corrected)

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.

CCR87411(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.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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: 01/21/2026

NARRATIVE

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CCR87465(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.

CCR87633(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.

CCR87463(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. (Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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: 01/21/2026

NARRATIVE

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CCR87458(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.

Civil penalties will be issued during today’s visit for the assessed dates of January 17 through January 20, 2026. Failure to correct the deficiencies may result in additional civil penalties.

An exit interview was conducted with Kevin Baas, Lead Caregiver. Civil penalties were provided for the assessed period of January 17 through January 20, 2026, please refer to LIC 421. A copy of this report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC809 (FAS) - (06/04)

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