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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601239
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:16:31 PM


Document Has Been Signed on 06/20/2023 04:16 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
EL SEGUNDO, 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: 3DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator, Tanios El HabarTIME COMPLETED:
04:30 PM
NARRATIVE
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On 06/20/2023 at 08:46 AM Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA España met with Richard De La Rama, Caregiver and Rosana Tan, Caregiver and conducted a risk assessment at the front door and discussed the purpose of the visit. The Manager, Nawal Sfeir arrived at the facility and join us for tour/annual. LPA was properly equipped with Fit tested N-95. 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 three (3) residents. Currently, there are two (2) hospice residents present during today’s visit.

During the tour, LPA observed the facility’s infection control practices. 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 required postings throughout the facility. All three (3) 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.

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. A comfortable temperature was observed 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 locked 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.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 06/20/2023 04:16 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed that the following staff members were missing CPR: Staff 1, Staff 2, Staff 3, and Staff 4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have all CRP of staff updatedto ensure resident safety. The licensee shall submit
plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the
resident's/staff's needs and services plans within 30 days of today's date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed that Staff record(s) were missing (S1) 1st, LIC9052, Fingerprint; (S2) 1st, LIC9052, (3) 1st, LIC9052, and (S4) 1st, ED, LIC501, LIC503, LIC508, LIC9052, FPCL/EXMP, ED, TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have all Staff records are upated ensure resident safety. The licensee shall submit
plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the
resident's/staff's needs and services plans within 30 days of today's 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 06/20/2023 04:16 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above.Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed that was no Admission/Intake Packet including admission agreement with addendums and personal rights, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have Admission/Intake Packet including admission agreement with addendums and personal rights updated to ensure resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's needs and services plans within 30 days of today's date.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/20/2023 04:16 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed that was no PUB 475 poster at the entryway of facitlity posted which must be 20"X26" which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have PUB475 updated to ensure resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's needs and services plans within 30 days of today's 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 06/20/2023 04:16 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed Emergency and Disaster Plan which was NOT approved by CCLD (i.e., there is a draft at the facility), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have Emergency and Disaster Plan updated to ensure resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's needs and services plans within 30 days of today's date.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Manager, Nawal Sfeir observed that was no oxygen report made in writing with fire jurisdiction that oxygen is in use at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The administrator/licensee agreed to have oxygen report made in writing with fire jurisdiction updated to ensure resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's needs and services plans within 30 days of today's 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MIKO INN
FACILITY NUMBER: 191601239
VISIT DATE: 06/20/2023
NARRATIVE
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The First Aid kit was available. Two (2) fire extinguisher were 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. Doorways were free of obstructions. Facility client records were reviewed. Three (3) staff files were chosen for random review. Staff have criminal record clearances and are associated to the facility. LPA observed water temperature in bathroom(s) #4, #5, #3 was shown to be between 105F and 120F.

The following deficiencies were cited:

· Staffing - Type B: 1569.618(c)(3)

· Personnel Records/Staff Training - Type B: 87412(a)

· Resident Records/Incident Reports - Type B: 87507(a)(1)

· Resident Rights/Information - Type B: 87468(c)(2)(A)

· Disaster Preparedness - Type B: 1569.695(a)(1)

· Residents with Special Health Needs - Type B: 87618(b)(3)(A)

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

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6