<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601239
Report Date: 01/10/2025
Date Signed: 01/10/2025 11:21:02 AM

Document Has Been Signed on 01/10/2025 11:21 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MIKO INNFACILITY NUMBER:
191601239
ADMINISTRATOR/
DIRECTOR:
TANIOS EL HABARFACILITY TYPE:
740
ADDRESS:3017 MALCOLM AVETELEPHONE:
(310) 446-1714
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY: 6CENSUS: 12DATE:
01/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Staff Richard DelaramaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/10/25, Licensing Program Analyst (LPA) Regina Cloyd made an unannounced visit regarding the relocation of six residents from The Palisades Villa, #197607174, 16629 W. Sunset Blvd. Pacific Palisades, CA 90272 to the facility listed above due to mandatory evacuation orders from Fire Advisory. LPA met with Staff Richard Delarama and explained the reason of the visit. LPA spoke with the Vice President of the Licensee, Nawal Sfeir, of both facilities over the phone.

During the visit, LPA conducted a health and safety check. LPA reviewed medication administration records (MARS) to obtain the names and date of birth from The Palisades Villa residents (R1 - R6). LPA interviewed The Palisades Villa staff (S1-S3) and retrieved names. LPA reviewed and obtained residents names from Miko Inn. LPA interviewed staff and retrieved names for Miko Inn's staff. Miko Inn's last fire drill was on 05/15/2024.

Per interview the licensee, six residents have been relocated to Miko Inn. The facility has sufficient beds, bedding, hygiene supplies and linens. The facility has five bathrooms. Per Staff, residents eat at the same time in their rooms and in the large family room. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications and MARS of The Palisades Villa residents have been transferred to Miko Inn and located in the living room. R1-R6 require incontinence care and are non-ambulatory requiring wheelchairs.

The Licensee stated each residents use different vendors, pharmacy and home health agencies, but the facility can maintain the same level of continued care for the residents. There is sufficient staffing available to provide care for residents of both facilities. It has been verified that a routine Fire inspection and testing was complete on 09/02/2023 and a fire drill was conducted on 05/15/2024. The licensee confirmed all families, responsible parties, home health, and hospice agencies for The Palisades Villa residents have been notified about the relocation either via calls, texts, or emails. The licensee stated that current Miko Inn residents will not be affected by this relocation. An exit interview was conducted with the Vice President Nawal Sfeir over the phone and a copy of this report was provided to Staff Rosana Tan.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 1