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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320246
Report Date: 12/10/2024
Date Signed: 12/10/2024 08:26:54 PM

Document Has Been Signed on 12/10/2024 08:26 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MIRAY LIFE CAREFACILITY NUMBER:
198320246
ADMINISTRATOR/
DIRECTOR:		PORCA, MICHELLE ANNFACILITY TYPE:
740
ADDRESS:3260 PINE AVENUETELEPHONE:
(310) 422-0950
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 5DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Michelle PorcaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 12/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Michelle Porca and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be on bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents. Currently, the facility has (2) residents in hospice care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, one (1) staff room, one (1) staff bathroom, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.9 degree F. A comfortable temperature of 73 degree was maintained in the facility.

LPA 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 residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 12/01/24. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.
Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MIRAY LIFE CARE
FACILITY NUMBER: 198320246
VISIT DATE: 12/10/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 03/28/24 – 03/28/25. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#5 (S1-S5) personnel files revealed to be maintained in order. The facility has the current administrator's certification on file for Michelle Porca #7015113740 - Expiration 02/14/26.

No deficiencies during this inspection visit.

An exit interview was conducted with Michelle Porca, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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