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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603406
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:42:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/18/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241218160327
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:
01/28/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Lea LoaizaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident developed pressure injuries in care.
Facility staff are not repositioning the resident as needed.
Facility staff are not meeting incontinence care needs of resident.
Facility staff speak inappropriately to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 01/28/2025, to deliver findings. Initial complaint investigation visit was conducted by LPA Ramirez on 12/24/2024 and needs further investigation was documented. LPA Ramirez was met by Back-up Administrator Lea Loaiza and explained the purpose of today’s visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-2 interviews (S1-S2), Resident interviews#1- 4 interviews (R1 – R4), Interview of R1’s responsible party, Resident#1- (R1): Emergency Contact Form, Physician Report, Centrally Stored Medication and Destruction Record (LIC 622), Resident Appraisal (LIC 603A), and physical plant tour.

See 9099-C for continued report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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-20241218160327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/28/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Resident developed pressure injuries in care - It is alleged R1 developed pressure injuries while receiving care at the facility. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. Physicians report (LIC 602A) dated 1/15/2025, revealed R1’s physician observed R1’s skin integrity to be normal and clear. R1’s physician did not observe bedsores or abrasions. Although the allegation 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.

Facility staff are not repositioning the resident as needed - It is alleged that staff are not repositioning R1 as needed. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. LPA Ramirez reviewed R1’s resident records including R1’s physician orders. LPA Ramirez did not observe a physician’s order indicating staff shall reposition R1. Although the allegation 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.

Facility staff are not meeting incontinence care needs of resident- It is alleged staff leave R1 soiled. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. During facility tour, LPA Ramirez observed six (6) out of the six (6) residents to be well groomed and residents’ rooms were not observed to be malodorous. LPA Ramirez observed all resident beds to contain disposable incontinence pads and required linens. LPA Ramirez observed the facility to have sufficient supply of incontinence care products. Although the allegation 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.

Facility staff speak inappropriately to resident – It is alleged staff spoke inappropriately to R1. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. During tour of facility, LPA Ramirez observed staff providing care and supervision. LPA Ramirez observed staff to be professional and did not observe staff speaking inappropriately to residents. Staff interviewed were knowledgeable on residents’ rights and on specific needs of the residents’ they serve. Although the allegation 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.

No deficiencies were cited during this investigation. Exit interview conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2