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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603218
Report Date: 01/28/2026
Date Signed: 01/28/2026 07:18:13 PM

Document Has Been Signed on 01/28/2026 07:18 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 IIIFACILITY NUMBER:
198603218
ADMINISTRATOR/
DIRECTOR:		MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:380 W BASELINE RDTELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Maxson Raharuhi, Asst. AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 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 Ana Aparicio and explained the reason for the visit. Maxson Raharuhi, Assistant Administrator arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older. The approved capacity is six (6) non-ambulatory residents. The facility is approved to retain no more than two (2) residents receiving hospice care.

There were two (2) 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. Oxygen was observed in use in the facility. Required “Oxygen in Use / No Smoking” signs were posted throughout the facility in visible locations. 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 four (4) resident bedrooms, one (2) restroom one being a guest restroom, living room, kitchen, laundry room, dining area, laundry room, garage, front yard, and backyard. Property includes a caregiver corridor near bedroom four (4). LPA observed four (4) 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.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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.

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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 III
FACILITY NUMBER: 198603218
VISIT DATE: 01/28/2026
NARRATIVE
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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) 113.2°F, bathroom (2) 111.5°F which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet. Smoke/carbon monoxide detectors were functional; fire extinguisher mounted in the kitchen. 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

Five (5) residents files were reviewed and contained current required documents Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports, ambulatory status and Rights acknowledgments. R1 and R2 were missing TB screenings. Five (5) residents’ medications were reviewed; medications were observed to be centrally stored in a locked cabinet in laundry room. It was observed that R1 and R3 require assistance from staff with administration of injectable medications. Additionally, R1 did not have Albuterol medication available.

Disaster Preparedness

Last fire/earthquake drill was conducted on January 27, 2026, with logs available. LIC 610D Emergency Disaster Plan was posted on front entry 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) staff files were reviewed and included criminal record clearances in all staff files. Current CPR/First Aid certificates were observed for S1-S3; however S4 certificate was expired, TB screenings documentation was present for S1-S3 however, no TB screening for S2 was observed. Required training was observed to be in files.

Insurance

Liability insurance was in compliance with an expiration date of April 4, 2026.

An exit interview was conducted with Ana Aparicio, 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 were provided.

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

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 07:18 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/28/2026 at 02:42 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: 01/28/2026

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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4
Based on record review, the licensee did not comply with the section cited above. One (1) 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: 02/13/2026
Plan of Correction
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The licensee agrees to ensure all S2 obtains a TB tests and physical examination. Proof of completed TB tests and physical exams for S2 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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 07:18 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/28/2026 at 02:42 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 in (1) out of (4) staff did not have a current CPR and First Aid certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee will submitted updated CPR and First Aid certificate for S4 by POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(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
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Based on record review, the licensee did not comply with the section cited above as two (2) out of four (4) residents did not have a TB examination on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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2
3
4
Licensee will submit proof of TB examination for R1 and R2 by POC due 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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 07:18 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/28/2026 at 02:54 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(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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4
Based on observation and record review the licensee did not comply with the section cited above in one (1) out of four (4) residents did not have a physciand order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee to submit proof of physicians order for bed rails for R1 by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 07:18 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/28/2026 at 03:29 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87629(a
(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above in one (1) out of five (5) residents requires assistance with the administration of injectable medication Enoxaparin (blood thinner) every 12 hours which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 01/29/2026
Plan of Correction
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2
3
4
Licensee to submit a plan on how the facility will meet this regulation by POC due date.
Type A
Section Cited
CCR
87628(a
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above in one (1) out of five (5) residents require assistance with the administration of injectable medication Lantus for Diabetes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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2
3
4
Licensee to submit a plan on how the facility will meet this regulation by POC due 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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 07:18 PM - It Cannot Be Edited


Created By: Gabriela Castro On 01/28/2026 at 03:35 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review the licensee did not comply with the section cited above in one (1) out of five (5) residents did not have a prescribed medication Albuterol (as needed) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
1
2
3
4
Submit a plan on how licensee will submit proof of medication being discontinued or submit proof of current medication order by physician and refill 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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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