191601239-10-26-2022-11-AS-AALR-CKKVRJ-20221026164002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601239
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:40:08 PM

Document Has Been Signed on 10/26/2022 04:40 PM - It Cannot Be Edited

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 INN		FACILITY NUMBER:	191601239
ADMINISTRATOR:	TANIOS EL HABAR		FACILITY TYPE:	740
ADDRESS:	3017 MALCOLM AVE		TELEPHONE:	3104461714
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS: 6	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Rosana Tan and Nawal Sfeir		TIME COMPLETED:	04:45 PM

NARRATIVE

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On 10/26/2022 Licensing Program Analyst (LPA) Antonia Alvizar 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 Alvizar 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.

On 10/26/2022, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Alvizar called Caregiver, Rosana Tan and conducted a risk assessment via-telephone and the purpose of the visit was explained. 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 four (4) resident. Currently, there are three (3) 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 properly screened for Covid-19 symptoms and temperature was checked by Caregiver, Rosana Tan. Later Manager Nawal Sfeir arrive to the facility and join us. LPA was properly equipped with Fit tested N-95.

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.

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SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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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Document Has Been Signed on 10/26/2022 04:40 PM - It Cannot Be Edited

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: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation water in bathroom 4 was shown to be at 129.8 F. the licensee did not comply with the section cited above in water temperature is maintained between 105.0 F. - 120.0 F. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2022
	Plan of Correction
1 2 3 4	Administrator will provide a written plan of action and pictures illustrating the correct water tempeture faxed to CCL by 10/27/2022

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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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: 10/26/2022

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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 residents.

Manager, Nawal provided to LPA a copy of Liability Insurance (Certificate of Property Insurance) and Premium Breakdown documentation.

LPA observed water in bathroom 4 was shown to be at 129.8 F which poses an immediate health, safety or personal rights risk to persons in care. During the visit LPA observed plumber corrected the water temperature.

This requirement is not met as evidence by:

Maintenance and Operation- Type A: 87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

An exit interview was conducted, and a copy of this report and citation was provided to Manager, Nawal Sfeir.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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