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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603406
Report Date: 05/02/2024
Date Signed: 05/03/2024 09:23:30 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230406145142
FACILITY NAME:FIL-AM HOME FOR SENIORS: LANSING'SFACILITY NUMBER:
198603406
ADMINISTRATOR:MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:1120 W. BRIARCROFT RD.TELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
05/02/2024
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Joanne Hernandez- StaffTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility failed to provide a safe environment for a resident in care.
INVESTIGATION FINDINGS:
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At 8:49 am Licensing Program Analyst (LPA) Sanjay Vaid was met by staff- Joanne Hernandez and Mark Reyes, explained the purpose of the visit, the administrator was notified. LPA and staff Hernandez toured the facility and conducted brief interviews with residents. Administrator- Lea Loaiza and Licensee -Toby Miclat arrived 30 minutes later and the purpose of the visit was discussed.

***This report supersedes the previous complaint report dated 04/09/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 04/09/24, and to remove the LIC 9099D deficiency cited. The Unsubstantiated Finding will remain the same**

Licensing Program Analyst (LPA) Sanjay Vaid and Tyler Reyes conducted a subsequent complaint visit on 04/09/24 regarding the allegation listed above to deliver complaint investigation findings. LPA Vaid and Reyes met with licensee-Toby Miclat and administrator- Lea Loaiza and discussed the purpose of the visit, which was to deliver complaint investigation findings.
.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230406145142
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LANSING'S
FACILITY NUMBER: 198603406
VISIT DATE: 05/02/2024
NARRATIVE
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On 04/13/2023, LPA Kruz Long, conducted the initial visit, during visit, LPA Long took a photo of the Staff/Resident rosters, attempted to obtain a copy of R#2's records (Physician's Report, Appraisal Needs and Services Plan). LPA interviewed Staff #1, #2 #3 and interviewed Resident #1 (R#1). Resident #2 (R#2) was not present in the facility.

On todays visit, LPA Vaid interviewed residents, owner, administrator, and staff, and toured the physical plant and observed the facility to be clean, in good condition and free of obstacles throughout.

Regarding allegation: Facility failed to provide a safe environment for a resident in care. It is alleged, that staff are not providing a safe environment for residents, as a resident was assaulted in the facility.
Interviews with 6 out of 6 residents revealed, residents are feeling safe and secure residing at the facility, and residents have not witnessed any assaultive behavior from other residents or staff. During the investigation, Resident #1 (R1) and Resident #2 (R2) were not interviewed, as R1 & R2 are deceased. Interviews with 5 out of 5 staff revealed, the staff treats residents in care with respect and kindness. Except for the incident in year 2023, no other assaultive behavior has been witnessed by the staff.

The investigation revealed, on 03/28/2023, R1 was assaulted by R2, and R1 did not sustain any injury. Staff who were present during the incident, separated R1 and R2, and staff performed assessed R1 for injury. Therefore, the investigation did not reveal any evidence to support that staff are not providing a safe environment for residents in care.

Based upon records review and interviews conducted, the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Lea Loaiza, Administrator. A copy of the licensing report was provided at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230406145142
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LANSING'S
FACILITY NUMBER: 198603406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87211(a)(1)(A)
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87211 (a)(1)(A) a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(A)Death of any resident from any cause regardless of where the death occurred, including but not limite... to visiting away from the facility.
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Plan of Correction: On 04/09/24, Administrator provided a copy of R2’s death certificate to LPA Vaid. Administrator to send an incident report (LIC624A) for R1 and R2 by POC Due date 05/06/2024.
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This requirement wasn't met as evidenced by: R2 was hospitalized on ?? and passed away on 04/16/23, however, facility failed to report R2 hospitalization and death to licensing per Title 22 regulations.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
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