374603273-2-20-2025-08-AS-JBAD-DE46SL-20250220200404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603273
Report Date: 02/20/2025
Date Signed: 02/20/2025 08:04:12 PM

Document Has Been Signed on 02/20/2025 08:04 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MYLDA SENIOR CARE FACILITY		FACILITY NUMBER:	374603273
ADMINISTRATOR/ DIRECTOR:	MIRIAM MEHZUN HADGU		FACILITY TYPE:	740
ADDRESS:	3535 FENELON STREET		TELEPHONE:	(619) 223-3700
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92106
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:50 AM
MET WITH:	Licensee Miriam Mehzun Hadgu		TIME VISIT/ INSPECTION COMPLETED:	08:15 PM

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

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Miriam Mehzun Hadgu.

According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents age 60 and above, one (1) of whom may be non-ambulatory in bedroom #1. The facility has a hospice waiver for 2 residents. During today’s inspection, there were a total of two (2) residents in care. This facility does not feature a secured perimeter or delayed egress doors.

During today’s visit, LPA observed two residents in care both of who were non-ambulatory. A review of the Physician Report indicated that R1 was non-ambulatory and R2 was also non-ambulatory due to using a walker and the facility only has clearance for one non-ambulatory resident. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

One deficiency was cited per California Code of Regulations, Title 22 for violation of facility's fire clearance.(refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Miriam Mehzun Hadgu, to whom a copy of this report, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Juliana Barfield	TELEPHONE: (619) 994-7269
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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 2

Document Has Been Signed on 02/20/2025 08:04 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MYLDA SENIOR CARE FACILITY	FACILITY NUMBER: 374603273
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87202(a)(1)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of person, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above when the licensee retained two non-ambulatory residents without the appropriate fire clearance in two out of two persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Licensee will request a new non-ambulatory fire clearance by end of business day tomorrow, (02/21/2025) to request an updated fire clearance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Juliana Barfield	TELEPHONE: (619) 994-7269
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2