191601239-9-1-2020-11-AS-EMAZ-BTRU4Z-20200924151557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601239
Report Date: 09/01/2020
Date Signed: 09/01/2020 03:48:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200609110638

FACILITY NAME:	MIKO INN		FACILITY NUMBER:	191601239
ADMINISTRATOR:	TANIOS EL HABAR		FACILITY TYPE:	740
ADDRESS:	3017 MALCOLM AVE		TELEPHONE:	(310) 446-1714
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS: 4	DATE:	09/01/2020
		UNANNOUNCED	TIME BEGAN:	12:37 PM
MET WITH:	TANIOS EL HABAR		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Resident sustained unexplained fall while in care

INVESTIGATION FINDINGS:

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On 09/01/20 Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Tanios El Habar/Administrator.

The investigation consisted of the following: An interview conducted with staff, residents and family members. A review of current staff/resident roster, (R-1's) a pre-placement appraisal, physician’s report, emergency contact information, needs and service plan, medications, admissions agreement, progress notes and medical records. An inspection of the facility 06/15/20 and 08/01/20.

Evaluation Report continues on LIC-9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200609110638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MIKO INN	FACILITY NUMBER: 191601239
	VISIT DATE: 09/01/2020

NARRATIVE

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Allegation: Resident sustained unexplained fall while in care

It is alleged Resident #1 (R-1) sustained an unexplained fall while in care. On 06/01/20, (R-1) was admitted to the hospital for observation due to some dark discoloration welts on the resident’s chest and arm. The daughter (W-1) who is also the Power of Attorney was notified by the administrator. An unusual incident report was submitted to the Community Care Licensing office on 06/16//20 on the incident.

During the investigation, LPA learned that there were no witnesses to determine what caused the bruises on (R-1’s) chest was caused by a fall. The facility staff (S1-S6) were not able to ascertain what caused the dark discoloration surrounding (R-1’s) chest and right arm. (S-4) noted that at the time (R-1) is restlessness and agitated, and will try to get out of bed, but no episodes of falling out of bed during his shift while he is on duty. (S-5) reports (R-1) was given a shower on 05/29/20 and no marks on (R-1’s) body. The following day 05/30/20, early in the morning when getting (R-1) ready for the day, (S-5) noticed a light green color on (R-1’s) chest like a bruise developing and there was no fall the night before. LPA was not able to gather information related to the incident from residents (R1-R4) due to their medical conditions.

Interviews were conducted staff (S1-S6) resident’s family members (W3-W5) were not able validated (R-1) suffered bruises from a fall. An interview with the daughter (W-1) and close personal friend (W-2) of (R-1), indicated that (R-1's) skin is very thin due to her medical conditions and that bruises easily, and did not think the facility did anything wrong. They state this facility is a good place. The department reviewed (R-1’s) service records including her medical records from Cedars-Sinai Hospital from 06/01/20 – 06/05/20 which included X-rays where it revealed no evidence of fracture or dislocation. There were no acute rib fractures were identified and no trauma contrast found. The facility conducted its own internal inquiry with the staff and was not able to conclude how the resident sustained these bruises. The facility does have a Fall Plan in place and that all staff has been trained on how to handle a resident’s fall. On 09/01/20, LPA conducted a follow up health and safety check of all residents and observed (R-1's) bruises have all disappeared. .

Based on the LPA’s observation, interviews, and a review of service/medical records that were conducted, the Department found there is no evidence to corroborate the allegation mentioned above.

Evaluation Report continues on LIC-9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200609110638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MIKO INN	FACILITY NUMBER: 191601239
	VISIT DATE: 09/01/2020

NARRATIVE

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Based on information gathered, the Department did not find sufficient evidence to support the allegation "Resident sustained unexplained fall while in care'.

Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid did or did not occur. Therefore, the allegation is "unsubstantiated.”

A telephonic exit interview was conducted with TANIOS EL HABAR, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020

LIC9099 (FAS) - (06/04)

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