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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603406
Report Date: 05/14/2024
Date Signed: 05/15/2024 01:10:34 PM

Document Has Been Signed on 05/15/2024 01:10 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: LANSING'SFACILITY NUMBER:
198603406
ADMINISTRATOR/
DIRECTOR:		MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:1120 W. BRIARCROFT RD.TELEPHONE:
(714) 408-8996
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
05/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Staff in Charge Joanne HernandezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sanjay Vaid and Licensing Program Manager (LPM) Fernando Fierros conducted a case management visit regarding deficiencies noted during visits conducted on 04/09/24 and 05/02/24. LPA Vaid met with lead staff, Joanne Hernandez, and spoke with Licensee Toby Miclat via telephone and discussed the purpose of the visit.

During 04/09/2024 visit, LPA Vaid interviewed Administrator and reviewed Resident #2 (R2) facility file. LPA obtained a copy of R2’s admission agreement, and any incident reports regarding R2.

Administrator reported R2 went on an outing with family for the period 04/13/23 through 04/16/2023 and R2 was expected to return to the facility on 04/16/2023. However, R2 did not return to the facility after the outing with family. On 04/15/2023, R2 was sent to the hospital for observation, while R2 was hospitalized, R2 passed away on 04/16/23 due to a medical issues. However, the facility failed to provide licensing with an incident report regarding R2s hospitalization and death. Per Administrator, R2 was never discharged from the facility. R2 was a resident of the facility when hospitalized on 04/15/2023 and on R2’s date of death.

Deficiencies cited per Title 22 Chapter 6 Division 8, Refer to attached LIC 809D.

Exit interview was conducted with caregiver, Joanne Hernandez. Licensing report and appeals rights were given.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 01:10 PM - It Cannot Be Edited


Created By: Sanjay Vaid On 05/14/2024 at 01:53 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: LANSING'S
FACILITY NUMBER: 198603406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87211(a)(1)(A)

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Reporting Requirements 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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Administrator to send an incident report (LIC624A) for R2 by POC Due date 05/17/2024.

On 04/09/24, Administrator provided a copy of R2’s death certificate to LPA Vaid.
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The requirement was not met as evidence by

R2 was hospitalized on 04/15/23 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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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