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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601239
Report Date: 06/07/2021
Date Signed: 06/07/2021 02:19:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MIKO INNFACILITY NUMBER:
191601239
ADMINISTRATOR:TANIOS EL HABARFACILITY TYPE:
740
ADDRESS:3017 MALCOLM AVETELEPHONE:
(310) 446-1714
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:6CENSUS: DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Caregiver, Rosana Tan TIME COMPLETED:
01:30 PM
NARRATIVE
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On 06072021 at 0943a Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Agard conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory residents and an approved hospice waiver for one (1) resident. Currently, there are two (2) hospice residents present during today’s visit.

LPA met with the Caregiver, Rosana Tan and both toured the inside and outside grounds of the facility. LPA was not properly screened for Covid-19 symptoms nor was temperature checked. LPA was properly equipped with Fit tested N-95 and gloves.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in a storage room; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio or front living room. LPA observed staff maintaining 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

LPA was unable to review the facility’s surveillance testing records. According to Administrator, staff are vaccinated and are no longer being covid tested weekly. Staff have not been fit tested for N95. Covid-19 Infection Control and Prevention training records were not available to LPA. In-service training on the approved mitigation plan were not reviewed. LPA did not observe newly admitted residents or newly hired staff.

All six residents with memory care needs. All rooms were inspected. Each resident has their own individual room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239
VISIT DATE: 06/07/2021
NARRATIVE
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personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 117 F. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were observed unlocked in storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. The First Aid kit was available. One fire extinguisher was observed in a box in the corner of kitchen area.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Overall facility was a bit cluttered. Doorways were free of obstructions.

The following deficiencies were cited:

1) Facility is approved from 1 hospice resident. Facility currently has 2 residents on hospice.

2) Back right stove burner not working.

3) Knives and other sharp items were unlocked

The following technical violations were issued:

1) LPA was not screened for covid symptoms upon entry.

2) No N-95 fit testing completed

3) No training for donning and doffing of PPE’s

4) No surveillance testing being conducted.

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s).



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed a sharp item in kitchen unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2021
Plan of Correction
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Cleared during visit, caregiver locked while LPA was present.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
87633(a)(2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) and record review, Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. LPA observed that the facilty was granted a hospice waiver for 1 residents & currently has 2 hospice residentswhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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Administrator is to send a request to licensing for an increase of hospice residents in the facility to 2 hospice resident per Title 22 Section 87633 & 87632 by POC due date.
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) LPA observed one burner on the stove was non-operational, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2021
Plan of Correction
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Administrator is to repair/replace stove burners, & send self-certification to licensing by POC due date
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: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5