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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320246
Report Date: 02/17/2023
Date Signed: 04/04/2023 02:16:24 PM

Document Has Been Signed on 04/04/2023 02:16 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:MIRAY LIFE CAREFACILITY NUMBER:
198320246
ADMINISTRATOR:PORCA, MICHELLE ANNFACILITY TYPE:
740
ADDRESS:3260 PINE AVENUETELEPHONE:
(310) 422-0950
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Michelean PorcaTIME COMPLETED:
10:00 AM
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On 02/17/23, Licensing Program Analysts (LPA) Lizeth Villegas and Licensing Program Manager (LPM)
Janae Hammond conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with Administrator Michellean Porca to explain the purpose of today’s visit. The facility is licensed to operate for 6 non-ambulatory residents of which 1 may be bedridden ages 60 and over and is approved hospice waiver for 6 residents.

The facility is a single story 7 bedroom 1 of which belongs to administrator, 2 common restrooms, 2 private restrooms, a detached garage for laundry service, dining area, kitchen, pantry, linen closet, 1 staff office and a designated outdoor shaded area. Facility has a signal system in all bedrooms and restrooms, the water temperature measured between 105- and 116-degrees F. The facility has a working landline telephone.
LPA and LPM toured the physical plant. There were no bodies of water or obstructions on the premises. Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA and LPM observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate, the last fire drill and disaster drill were on 11/01/22.

During the visit, LPA and LPM observed the facility's infection control practices. LPA and LPM observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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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: MIRAY LIFE CARE
FACILITY NUMBER: 198320246
VISIT DATE: 02/17/2023
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and LPM observed staff wearing face coverings, LPA and LPM observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan. The facility has submitted an Infection Control Plan to the regional office.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Michellean Porca.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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