374603273-2-15-2024-08-AS-DPEA-D2GLQ3-20240215075652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603273
Report Date: 02/13/2024
Date Signed: 02/15/2024 07:57:16 AM

Document Has Been Signed on 02/15/2024 07:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MYLDA SENIOR CARE FACILITY		FACILITY NUMBER:	374603273
ADMINISTRATOR:	MIRIAM MEHZUN HADGU		FACILITY TYPE:	740
ADDRESS:	3535 FENELON STREET		TELEPHONE:	(619) 223-3700
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92106
CAPACITY:	6	CENSUS: 0	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Miriam Mehzun Hadgu, Administrator		TIME COMPLETED:	05:00 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) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee, Miriam Hadgu. The facility is approved to serve six (6) elderly residents age 60 and above; one (1) of which may be non-ambulatory in Bedroom #1 only. Hospice approved for two resident two (2) residents. The facility was undergoing repairs on the day of the inspection. Two residents were relocated on 1/31/2023. One resident was transferred to Baron's Presido University City (374603323) and one returned to their residence in Nevada. Per Licensee Hadgu, both residents will return once the repairs are complete in approximately two weeks. Licensee Hadgu will submit an Incident Report with update to CCLD. During the inspection, LPA toured the interior and exterior of the facility and observed resident rooms. The facility was organized, kempt and in good repair. The kitchen was out of service and cabinets, sink and dishwasher had been removed. Due to the out of service status of the kitchen, food supplies were not evaluated. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Pathways inside the property were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. No pools or bodies of water were observed on the premises. Per Licensee, Hadgu, no firearms or ammunition are kept at the facility. Carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher was present and operational. First aid kit was observed and readily accessible.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MYLDA SENIOR CARE FACILITY	FACILITY NUMBER: 374603273
	VISIT DATE: 02/13/2024

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Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured in resident restrooms and the kitchen recorded at 106, 107.1 and 106.2 degrees Fahrenheit which are within Title 22 Regulations. LPA reviewed staff and resident records/files. The files which LPA reviewed contained the required documents. Confidential records were stored in locked areas. LPA provided the licensee consultation on reporting requirements and Infection Control Plans. LPA also provided licensee with the electronic version of the LIC9282.

No deficiencies were observed or cited during today's annual inspection.

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

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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