191601239-10-21-2021-11-AS-AJKK-C89TTR-20211029150109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601239
Report Date: 10/13/2021
Date Signed: 10/21/2021 02:16:17 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2021 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211006162934

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: 5	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Caregiver, Nydea Dimagiba		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff does not adhere to mask mandate

INVESTIGATION FINDINGS:

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On 10/13/2021 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation at the above facility to address the following allegation. LPA Agard was met with caregiver, Rosana Tan and explained that the purpose of the visit was to gather information.

The investigation consisted of the following: LPA Agard toured the facility and conducted interviews with staff, the resident’s responsible parties and evidence provided.

On 10/13/2021 LPA Agard delivered findings.

Regarding the allegation: Staff does not adhere to mask mandate. It’s being alleged that a caregiver either does not wear a mask or improperly wears a mask positioned below his nose. The licensee is informing staff and families that there’s nothing that can be done about the staff not adhering to the mask policy.
Continue on 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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-20211006162934

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
MONTEREY PARK, CA 91754

FACILITY NAME: MIKO INN	FACILITY NUMBER: 191601239
	VISIT DATE: 10/13/2021

NARRATIVE

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The investigation revealed the following: S1 confirm that there is a staff person that is not complying with the mask mandate nor are they willing to be tested weekly. S1 states, S6 is no longer able to work with clients but performs duties such as cleaning. S2 states that they always have to “correct” S6 about wearing a mask while in the facility. “The facility staff and families are scared they or their family member might catch covid due to the persons exposure while on public transportation.” S3 states not knowing the staff person. S4 confirmed the allegation to be true and states they have received several complaints from the families regarding S6. S5 states having to remind the staff to put on their mask. “S6 usually complies when I ask them to put on their mask.” S6 states that they only wear a mask around other people regardless of being in the facility. They state, “they do not trust being tested so they do not comply because it is a violation of their constitutional right.”

During an interview with witnesses the following was discovered: RP states, S6 has expressed their opinion in being against vaccination, testing and wearing a mask as reason not to follow the mask mandate. W1 states they have expressed concern to the licensee over S6 lack of compliance. “It’s alarming that the facility hasn’t done anything.” W2 states, S6 will put on a mask only when “I or the families walk into the facility and will take it off once we leave.” W2 states they have walked in many times to see S6 without a mask.

LPA attempted to conduct interviews with the residents, but they were not capable of responding to interview questions.

The following Provider Information Notice (PIN) was provided to the Licensee that addresses unvaccinated staff, weekly testing, mask mandate and full vaccination mandate (Nov 2021): PIN 21-32.1-ASC, PIN 21-38-ASC and PIN 21-44-ASC

Based on the investigators interviews conducted with licensee, caregivers, families of the residents, and evidence provided, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted with caregiver and a hard copy was provided with appeal rights.
See LIC 9009-D on the next page.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20211006162934

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
MONTEREY PARK, CA 91754

FACILITY NAME: MIKO INN	FACILITY NUMBER: 191601239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2021 Section Cited CCR 87468(a)	1 2 3 4 5 6 7	87468 Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in....Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.	1 2 3 4 5 6 7	Licensee will ensure the staff member shall wear a face covering, unless an individual's exemption applies, while in the facility. Licensee will provide staff with the PIN addressing testing and mask mandate and submit a training for the staff on wearing face coverings by POC due date.
	8 9 10 11 12 13 14	This requirement was not met based on evidence provided, admission from the licensee of a staff person that is not complying with the facility mandate which require mask be worn and weekly testing of unvaccinated staff. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
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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 Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

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