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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601922
Report Date: 06/19/2023
Date Signed: 06/19/2023 02:20:26 PM

Document Has Been Signed on 06/19/2023 02:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MYRA'S GOLDEN HEART HOMEFACILITY NUMBER:
198601922
ADMINISTRATOR:JAY SAHAGUNFACILITY TYPE:
735
ADDRESS:3150 PADDY LANETELEPHONE:
(626) 813-6820
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 1DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Michelle SahagunTIME COMPLETED:
02:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Michelle Sahagun (Administrator) and explained the purpose of the visit. The facility is licensed to serve 6 adults.Two (2) can be non-ambulatory.

LPA use the CARE tool for this visit.

LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff were still cleaning during visit and disinfecting throughout the day. Sufficient PPE supplies but does not have an Infection Control Plan posted by the entrance. The facility has rodent infestation.

Due to lack of time LPA will return another day to complete the inspection.

Deficiency cited (see 809D)

Exit interview conducted and copy of report given to administrator Michelle Sahagun
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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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Document Has Been Signed on 06/19/2023 02:20 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/19/2023 at 01:55 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MYRA'S GOLDEN HEART HOME
FACILITY NUMBER: 198601922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(b)(1)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply:  (1) In addition to the requirements of subsection (a)(2), assigned staff and volunteers, regardless of having direct contact with clients, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the communicable disease. Enhanced environmental cleaning and disinfection shall be of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Rodent droppings where seen and photographed by LPA inside the broiler. Administrator stated rat comes in thorough the roof which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Administrator will address the rodent problem and send proof to LPA by plan of correction date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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