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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603310
Report Date: 04/24/2024
Date Signed: 04/24/2024 09:49:30 PM


Document Has Been Signed on 04/24/2024 09:49 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:MIRACLE MILE MANOR RCFEFACILITY NUMBER:
198603310
ADMINISTRATOR:NAGEL, EDITHFACILITY TYPE:
740
ADDRESS:6273 DEL VALLE DRIVETELEPHONE:
(323) 807-0549
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Edith NagelTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Edith Nagel , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents of which (1) maybe bedridden, and an approved hospice waiver for 4 resident. Currently Two (2) residents are diagnosed with dementia. Two residents are on hospice. No residents are receiving home health care services at time of this visit. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (5) resident bedrooms, (4) Full bathroom, living room, kitchen , dining room, laundry room (located in the kitchen) and an outdoor shaded patio area. A fenced pool in the backyard was observed and was within Title 22 guidelines. LPA toured the Resident bedrooms and they had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 108F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310
VISIT DATE: 04/24/2024
NARRATIVE
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Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:

-On 4/24/24 at 10:00 AM LPA reviewed staff files and found that all staff records were incomplete. LPA asked Administrator for required documents according to Title 22 and each staff file was incomplete including Administrators. Administrator stated she will have to find the documents.-

An exit interview was conducted and a copy of Report and Appeal Rights provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/24/2024 09:49 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: MIRACLE MILE MANOR RCFE

FACILITY NUMBER: 198603310

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. All staff records were incomplete : including First Aid certificate,LIC 503 Health screening w/ TB and LIC 501.
POC Due Date: 05/15/2024
Plan of Correction
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Administrator agrees to send missing documents for All staff to licensing before POC date : Send documents to : Sparkle.day@dss.ca.gov
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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