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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603218
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:38:48 PM

Document Has Been Signed on 12/05/2022 04:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FIL-AM HOME FOR SENIORS IIIFACILITY NUMBER:
198603218
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:380 W BASELINE RDTELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 5DATE:
12/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Lea Loaiza TIME COMPLETED:
04:43 PM
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During 10 day complaint visit, LPA and Administrator noticed several items of food had expired:
Mayonnaise - expired - 06/01/2022
4 times Cream of chicken - expired 10/08/2022
Granola yogurt Parfait - expired - 1/24/2022

LPA and Administrator also observed expired medications that included:
Glucose Injection for past resident - expired 02/15/2022
Fervano Expired 03/31/2
Ducaliquid x2 expired 09/2021, 07/2022
Pedialyte expired 02/01/2022
Humilin for past resident expired 05/11/22
Lorazepam expired 02/01/2022
Morphine for past resident expired 02/09/2022

LPA and administrator also observed knife in unlocked drawer in kitchen.

LPA and administrator also observed refrigerator in garage was uncleaned.

Deficiencies cited, please see 809D for details. At the time of visit no other deficiencies were observed.

Exit interview done with Administrator Lea Loaiza and copy of report and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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Document Has Been Signed on 12/05/2022 04:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/05/2022 at 03:15 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
87465(i)

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Health Related Services. Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.

This requirement was not met by evidence of:
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Administrator will dispose properly of expired medications by delivering them to a pharmacy and make a list of items that were taken to be destroyed and send proof to LPA by POC date
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LPA and administrator observed medications listed on 809 that did not belong to residents and/or had expired which poses a health and safety treat to residents in care
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Type A
12/06/2022
Section Cited
CCR87555(b)(9)

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87555(b)(9) General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service

This requirement is not met as evidenced by:
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Administrator disposed of all exired food and will rotate food in storage to prevent facility food from expiring. Administrator will send a written plan to LPA by POC date on how they will address the issue.
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LPA and administrator observed items of expired food. (see list on 809) which poses a health and safety threat to residents in care
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/05/2022 04:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/05/2022 at 03:41 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited
CCR
87705(f)(1)

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87705(f)(1) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s).
This was not met as evidenced by:
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Administrator locked the knife during the visit, ***no further action is required***
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LPA and administrator observed knife in unlocked drawer in kitchen which poses a health and safety threat to residents in care.
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/05/2022 04:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/05/2022 at 03:55 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 III
FACILITY NUMBER: 198603218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2022
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Administrator will clean the refrigerator in the garage and send photo as proof to LPA by POC DATE.
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LPA and administrator observed refrigerator in garage in uncleaned condition which poses a health and safety threat to persons in care.
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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