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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880783
Report Date: 09/01/2026
Date Signed: 09/01/2026 11:35:28 AM

Document Has Been Signed on 09/01/2026 11:35 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FIL-AM HOME FOR SENIORS IVFACILITY NUMBER:
361880783
ADMINISTRATOR/
DIRECTOR:		MICLAT, TOBYFACILITY TYPE:
740
ADDRESS:359 W LANGSTON STREETTELEPHONE:
(714) 408-8996
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 4DATE:
09/01/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ruben Reyna- CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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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.
Efren Malagon
Paola Guerrero
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/01/2026 11:35 AM - It Cannot Be Edited


Created By: Paola Guerrero On 09/01/2026 at 11:03 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FIL-AM HOME FOR SENIORS IV
FACILITY NUMBER: 361880783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87615(a)(1)

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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:
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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.
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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.
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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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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