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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603310
Report Date: 04/10/2023
Date Signed: 04/10/2023 02:21:09 PM

Document Has Been Signed on 04/10/2023 02:21 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: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: DATE:
04/10/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Edith NagelTIME COMPLETED:
02:30 PM
NARRATIVE
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On 4/11/2023, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced One-Year Required Visit at the facility. LPA met with the Licensee Edith Nagel and conducted a risk assessment. Facility is approved to serve 5 non-ambulatory residents and 1 bedridden resident over the age of 60.
LPA reviewed client records, staff records, medications, and inspected the entire facility.

LPA and Edith inspected the entire facility inside and out. The facility has 5 resident bedrooms, 3 bathroom and 1 staff bathroom, a living room, a fireplace in the living which is cover by a metal fireplace screen. a dining room, and a kitchen. The outdoor facility has a backyard with a pool inaccessible with a 5-foot fence around it.

All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Water temperature measured 112.7 degrees.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was operational. Smoke detectors were working properly, fire extinguishers were fully charged and operational, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and in order. Exits/Walkways around the home were free of debris and hazards.

Continued on LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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 5
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: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310
VISIT DATE: 04/10/2023
NARRATIVE
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During today’s visit LPA observed that the facility has a half bed rail for R1 and R3 with no prescriptions in the file.

LPA Shirley noticed during record review that Staff Iann Barrantes, Anita Lebon and Guadalupe Castillo were listed on the LIC500 Staff Roster but have no background clearance.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


During today’s visit there were deficiencies observed, Title 22 Chapter 6 Regulations are being cited.

Please see LIC809- D.

Exit interview held. A copy of the report and appeals rights was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/10/2023 02:21 PM - It Cannot Be Edited


Created By: Felisa Shirley On 04/10/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in which having an employee working without background clearance poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee Edith stated, that she will send staff to get fingerprint clearance today.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/10/2023 02:21 PM - It Cannot Be Edited


Created By: Felisa Shirley On 04/10/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023

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, and record review the licensee did not comply with the section cited above in which persons working without background clearance poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee Edith stated that she will send staff to get fingerprint clearance today
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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.
POC Due Date: 04/11/2023
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/10/2023 02:21 PM - It Cannot Be Edited


Created By: Felisa Shirley On 04/10/2023 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to health and safety code
section 1522 shall prior to working, resideing or volunteering in a licensed facililty.

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record reveiw the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee Edith stated, she will be sending staff to be fingerprinted for background check.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5