Fil-Am Home for Seniors IV

Type of visit: Case Management - Deficiencies

On September 1, 2026, Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to conduct a Case Management visit regarding a Special Incident Report (SIR) received by the Department on August 11, 2026. The SIR stated that on July 24, 2026, Resident 1 (R1) was relocated from the facility because R1 required a higher level of care. On August 12, 2026, LPA contacted the telephone number listed on the SIR and spoke with Facility Administrator Toby Miclat regarding the incident and to obtain additional information concerning R1 and the circumstances surrounding R1’s relocation. The Facility Administrator informed LPA that R1 was admitted to the facility on July 15, 2026, and was receiving wound care services from Pacifica Wound Care for an unstageable wound. The Administrator further stated that R1 was not receiving hospice services and did not have an exception letter from the Community Care Licensing Division (CCLD) authorizing the facility to admit and provide care to R1 prior to admission. LPA informed the Facility Administrator that prohibited health conditions, including Stage 3 or higher pressure injuries, require an approved exception from CCLD or, where applicable, the resident must be receiving care from a hospice agency in accordance with applicable regulations. LPA further informed the Administrator that residents with prohibited health conditions may not be admitted or retained without the required authorization. Based on the information obtained, LPA informed the Facility Administrator that a deficiency would be issued for admitting R1 with a prohibited health condition without the required exception or applicable hospice services. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Care giver Ruben Reyna at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 2, 2026

87615 Prohibited Health Conditions…. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly…. (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on record review, interviews, the licensee did not adhere to the regulation stated above by admitting R1 with a prohibited health condition without the required exception or applicable hospice services, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: The licensee has agreed to read regulation: 87615 (a)(1) and provide training to all care staff regarding Prohibited Health Conditions: For any Stage 3 or higher-pressure injuries, an approved exception from CCLD must be issued if the resident is not receiving care from a hospice agency. The Licensee will provide proof of training signed and dated by all staff by POC date 9/2/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Caregiver Ruben Reyna and was granted entry to the facility. At the time of the visit there was two (2) staff present, and four (4) residents present. The facility is a five (5) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, with an attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (4). LPA was accompanied by Facility Caregiver, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. During record review LPA found that Fire and disaster drills have not been conducted since 2025. During review of record LPA observed Liability insurance to be on file however, liability held an expiration date of 8/24/26 liability insurance was not current. LPA will be issuing deficiencies. Based on the observations made during today’s visit, two deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Caregiver Ruben Reyna.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Facility Administrator Lea Loaiza and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The facility is a five (5) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, with an attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (5). LPAs was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathrooms to be 112.6 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Lea Loaiza.the state’s words, verbatim · CDSS document, Sep 10, 2024