198603310-5-6-2022-11-AS-JHAD-CEXVPC-20220531163631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603310
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:05:01 PM

Unsubstantiated

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
01/28/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220128122541

FACILITY NAME:	MIRACLE MILE MANOR RCFE		FACILITY NUMBER:	198603310
ADMINISTRATOR:	NAGEL, EDITH		FACILITY TYPE:	740
ADDRESS:	6273 DEL VALLE DRIVE		TELEPHONE:	(323) 807-0549
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Edith Nagel, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident has loss an excessive amount of weight.
Resident is not awarded privacy.
Staff are not meeting resident's hygiene needs.
Resident's admissions agreement doesn't have a list of fees.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Edith Nagel, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 02/04/22, LPA Soto interviewed Administrator, S#2, R#1, and R#2. LPA received the following documents on 02/04/22: Resident Roster, Staff Schedule, Face sheet/assessment, Facility notes dated from 08/06/21 – 01/25/22, Shower/sponge bath schedule, Emails dated 01/14/22 & 01/18/22, 01/28/22 – 01/31/22 (copy of text thread), Admission agreement, Physician’s report, Rent invoice, Covid test results, Weight chart, and SIR dated 01/16/22.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 11-AS-20220128122541

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: MIRACLE MILE MANOR RCFE	FACILITY NUMBER: 198603310
	VISIT DATE: 05/06/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following for Allegation #1 – Resident has loss an excessive amount of weight. Interviews with Administrator and S#2, the reason R1 has lost weight because R1 was started on a soft diet and R1 refuses to eat. Sometimes R1 not hungry and they cannot force feed R1. Some days R1 eats all the food they provided R1 and the next day, R1 might not want anything to eat. Interviews with R1, said, “If she hungry she eats, but she not hungry all the time, don’t feel like eating, not that much.” Interviews with R2, said, “I get well balanced meals, 3 times a day. Vegetables are a little over cooked, but I eat them.” LPA reviewed R1 physician's R1 is losing weight, but not because of malnutrition, R1's appetite has just diminished. Facility feeding R1 a well-balanced meal with fresh vegetables, protein, fresh fruits, and ensure drinks. The interviews and records reviewed did not concur with above allegation.

Allegation #3 - Resident is not awarded privacy. Interviews with Administrator and S#2, R1 cannot hold telephone when she gets calls. The staff needs to assist her with the phone and R1 can’t hardly hear, so R1 has trouble hearing the person that calls R1. They leave the room when they hand her the phone, but again R1 is hard at hearing. R1 is awarded privacy. Interview with R2, R2 does have privacy, R2 shares a room with R1, R2 does see Administrator leave the room when R1 is on the phone, R1 cannot really hear. R2 always get privacy when R2 is on the phone. The interviews conducted do not concur with the above allegation.

Allegation #4 - Staff are not meeting resident's hygiene needs. Interviews with Administrator and S#2, R1 get a sponge bath 3x times a week and a shower once a week, in R1 beds. They wrap the bed in plastic and give R1 a shower in the bed. It’s hard for R1 to get up and take shower R1 cannot sit or stand. Interview with R2, R2 takes care of own hygiene needs. R2 shares a room with R1. Interview with R1, said, “don’t get sponge bath or showers.” R2, interrupted, and said, “Yes, you do, they give sponge baths and showers.” LPA reviewed shower/ sponge schedule, sponge bath is given 3x times a week and shower once a week. LPA observed r1 nails, they were clean. The interviews, records reviewed, and observations conducted do not concur with the above allegation.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
01/28/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220128122541

FACILITY NAME:	MIRACLE MILE MANOR RCFE		FACILITY NUMBER:	198603310
ADMINISTRATOR:	NAGEL, EDITH		FACILITY TYPE:	740
ADDRESS:	6273 DEL VALLE DRIVE		TELEPHONE:	(323) 807-0549
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Edith Nagel, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Nurse denied entry into facility to assess resident

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20220128122541

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: MIRACLE MILE MANOR RCFE	FACILITY NUMBER: 198603310
	VISIT DATE: 05/06/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following
for Allegation #2 - Nurse denied entry into facility to assess resident. Interviews with Administrator on 02/04/22, on 01/20/22, R1’s family member sent a nurse from another facility to evaluate R1, Administrator denied the nurse entry because R1 family member did not give her prior notice and family member had not paid rent for the month. Administrator admitted that she denied entry to the nurse and LPA reviewed a text tread between administrator and R1 family member, where it showed that Administrator is telling family member did deny entry to the nurse. Administrator did not have to deny entry to nurse for assessment. The interviews and records reviewed did concur with the above allegation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Edith Nagel, Administrator and a copy of Report and Appeal Rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20220128122541

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: MIRACLE MILE MANOR RCFE	FACILITY NUMBER: 198603310
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/16/2022 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 (a)(11) to have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This was not met as evidence by:	1 2 3 4 5 6 7	Administrator to create a plan where she explains how will she avoid this in the future. To provided to LPA on or before POC due date.
	8 9 10 11 12 13 14	Based on observations and interviews administrator denied entry to nurse, which potentially poses a health and safety risk for persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20220128122541

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: MIRACLE MILE MANOR RCFE	FACILITY NUMBER: 198603310
	VISIT DATE: 05/06/2022

NARRATIVE

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Allegation #5 - Resident's admissions agreement doesn't have a list of fees. Interview with administrator. The admissions agreement shows that $250 is owed for optional services. LPA reviewed admissions agreement and it does show the additional charge for $250 is for optional services. The administrator gave R1 family member the correct payment owed for monthly rent.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

An exit interview was conducted with Edith Nagel, Administrator, and a copy of report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 6