198320246-1-26-2022-11-AS-JCAS-CB38WK-20220126215252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320246
Report Date: 01/26/2022
Date Signed: 01/26/2022 09:53:37 PM

Document Has Been Signed on 01/26/2022 09:53 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	MIRAY LIFE CARE		FACILITY NUMBER:	198320246
ADMINISTRATOR:	PORCA, MICHELLE ANN		FACILITY TYPE:	740
ADDRESS:	3260 PINE AVENUE		TELEPHONE:	(310) 422-0950
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 6		CENSUS: 0	DATE:	01/26/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Applicant, Michelle Ann Porca		TIME COMPLETED:	04:05 PM

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Licensing Program Analysts (LPAs) Jey Cardenas and Antonia Alvizar made an announced visit, and met with the Applicant, Michelle Ann Porca also present was back up administrator Jon Camlas. LPA Cardenas conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. An application was received by Community Care Licensing Department (CCLD) on 09/14/21 for an initial application to serve residents ages 60 and over. The requested capacity is for total six (6) residents, of which five (5) may be non-ambulatory and one (1) bedridden. Rooms #2 and #4 approved for bedridden resident.

Structure The facility is a one story home in a residential neighborhood. The facility has a living room, dining area, kitchen, office, seven (7) bedrooms of which six are designated for residents and one (1) is for staff. Four (4) bathrooms, garage with laundry space. Facility has one working telephones located in the kitchen. Beds have required lines/ supplies pillowcase, fitted sheets, blankets, Bathrooms: bathrooms have working toilet, sink, and standing showers. Secured grab bars and skid mats observed. Food Service: Sufficient plates and cups were observed in the home, Knives, cutlery, and other sharp kitchen utensils are inaccessible and under lock. Full charged fire extinguishers located throughout the facility.

Smoke Detectors/Carbon Monoxide(s): LPA observed dual/ hardwired with battery back up smoke detectors/ carbon monoxide mounted on ceiling located in the kitchen, hallways, and bedrooms. Appliances: there is a microwave, one working refrigerators, toaster, microwave, water dispencer, and rice cooker available. Toxins: Cleaning supplies and toxins are stored near separate kitchen bottom cabinet which remains locked. Water Temperature: Hot water was tested in residents bathroom on both ends of facility, water measured at 119.1 and 107.9 degrees Fahrenheit. Medication, First-Aid Kit & Book: LPA observed standing cabinet located in the office which will be used for medication. First aid kit, and first aid book available at time of visit. Clients & Staff Files: Designated area for files are located in a locked file cabinet located in office area. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. No fire arms in the home. LPA observed activities,

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MIRAY LIFE CARE	FACILITY NUMBER: 198320246
	VISIT DATE: 01/26/2022

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board games for residents. Fire Clearance: Fire clearance was approved on 12/14/21, fire clearance granted. Facility is equipped with auditory alarm devices in exits. Facility will not handle residents cash resources.

Component III ; LPAs reviewed component III with applicant. When the applicant was ask if they understood Title 22 regulations they responded in the affirmative.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPAs will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application. Pre Licensing is complete and has no corrections to make.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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