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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603406
Report Date: 05/14/2024
Date Signed: 05/15/2024 01:07:07 PM

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:
05/14/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Staff in Charge, Joanne HernandezTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility failed to provide a safe environment for a resident in care
INVESTIGATION FINDINGS:
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This report supersedes the previous complaint reports dated 04/09/24 and 05/02/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 04/09/24 and 05/02/24, and to remove the LIC 9099D for the citation which was issued erroneously.The findings will remain the same.

On today's visit Licensing Program Analyst (LPA) Sanjay Vaid and Licensing Program Manager (LPM) Fernando Fierros conducted a tour of the physical plant along with caregiver Joanne Hernandez, and obtained staff and resident roster. All passages are clear of debris, facility is clean and in good repair.

On 05/02/24, Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent visit and met with staff Joanne Hernandez and staff Mark Reyes, staff notified the Administrator of Licensing's visit. 30 minutes later, Administrator, Lea Loaiza and Licensee,Toby Miclat arrived at the facility and the purpose of the visit was discussed. LPA and staff Hernandez toured the physical plant and observed the facility to be clean, in good condition, and free of obstacles throughout. LPA Vaid conducted interviews with residents.
Unsubstantiated
Estimated Days of Completion: 0
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 2
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: 05/14/2024
NARRATIVE
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On 04/09/24, Licensing Program Analyst (LPA) Sanjay Vaid and Tyler Reyes conducted a subsequent complaint visit 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.

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.

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 residing at the facility feel safe and secure, 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 with respect and kindness. Staff reported the only incident witnessed by staff regarding assaultive behavior occurred on 03/28/23 between R1 and R2. Staff separated the residents and reported no visible injuries were noted. Therefore 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 Staff in Charge - Caregiver Joanne Hernandez. 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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2