198603406-2-11-2023-28-AS-KRAZ-CNXUC2-20230211142713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603406
Report Date: 02/11/2023
Date Signed: 02/11/2023 02:27:20 PM

Document Has Been Signed on 02/11/2023 02:27 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: LANSING'S		FACILITY NUMBER:	198603406
ADMINISTRATOR:	MICLAT, TOBY		FACILITY TYPE:	740
ADDRESS:	1120 W. BRIARCROFT RD.		TELEPHONE:	(714) 408-8996
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 6	DATE:	02/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:33 PM
MET WITH:	Administrator Toby Miclat		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/11/2023 at 12:25 pm. LPA was met by Staff #1 (S1) and explained the purpose of the visit. At 12:42 pm Administrator Toby Miclat later arrived to assist in tour. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for four (4) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), and Administrator Miclat will submit copy of liability insurance.

LPA OBSERVATIONS: Tour began at at 12:45 pm and was led by Administrator Miclat. The Facility is a single story building in a residential area with six (6) resident bedrooms, dining room, four (4) bathrooms, kitchen, laundry room/pantry and attached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen/Pantry: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 114.3 degrees F. Signs promoting hand washing were observed. Sharps were secured in cabinet to the right of refrigerator and inaccessible to residents. Cleaning solutions and disinfectants were observed to be locked in cabinet directly under kitchen sink and inaccessible to residents. Pantry contained emergency water supply and emergency food supply. Extra PPE was observed to be stored in kitchen cabinet near sink.

· Dining Room/Family Room/TV Room: Dining room was observed to be clean and contained table and chairs. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: LANSING'S	FACILITY NUMBER: 198603406
	VISIT DATE: 02/11/2023

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·Linen Closet: Contained plenty linens, towels, and hygiene products.

· Resident Rooms 1 - 6: All contained the required furnishings, linens and were observed to be clean. All bedrooms are private, two (2) of those bedrooms contain private bathrooms.

· Bathrooms: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Grab bars were observed near toilet and shower. Water temperature in this bathroom was measured at 114.3 degrees F which is in the required 105 – 120 degrees F. Private resident bathroom #2 located in resident bedroom #3 water temperature was measured at 106.5 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower. Private resident bathroom #3 located in resident bedroom #5 water temperature was measured at 115.6 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower. Private resident bathroom #4 located in resident bedroom #6 water temperature was measured at 106.9 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower.

· Centrally Stored Medications: Is in kitchen cabinet and was observed to be secured and inaccessible to residents. LPA reviewed 6 out of 6 resident medications.

· Attached Garage: LPA observed chemicals and extra bedding supplies. Garage was locked and inaccessible to residents.

· Laundry Room: is connected to pantry room and secured.

· Backyard: Clean and free from hazards. LPA observed a pool with water. Pool water was clear and pool is surrounded by a locked gated.

Administrator certificate was observed for Toby Miclat with an expiration date: 10/12/23. LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Several fire extinguishers were observed in the facility and were fully charged.

No deficiencies were cited during visit. One (1) technical advisory was noted. Exit interview was conducted with Staff #1 (S1) and a copy of this report and appeals rights was left.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

LIC809 (FAS) - (06/04)

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