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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603310
Report Date: 04/19/2022
Date Signed: 04/22/2022 09:47:49 AM

Document Has Been Signed on 04/22/2022 09:47 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MIRACLE MILE MANOR RCFEFACILITY NUMBER:
198603310
ADMINISTRATOR:NAGEL, EDITHFACILITY TYPE:
740
ADDRESS:6273 DEL VALLE DRIVETELEPHONE:
(323) 807-0549
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 6CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Edith NagelTIME COMPLETED:
01:27 PM
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On 4/19/2022, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced One-Year Required Visit at the facility. LPA met with the Licensee Edith Nagel and conducted a risk assessment. Facility is approved to serve 5 non-ambulatory residents and 1 bedridden resident over the age of 60.
LPA reviewed client records, staff records, medications, and inspected the entire facility.

LPA and Edith tour the entire facility inside and out. The facility has 5 resident bedrooms, 3bathroom and 1 staff bathroom, a living room, a fireplace in the living which is cover by a metal fireplace screen. a dining room, and a kitchen. The outdoor facility has a backyard with a pool inaccessible with a 5-foot fence around it. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Water temperature measured 111.4 degrees.
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was operational. Smoke detectors were working properly, fire extinguishers were fully charged and operational, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Continue on LIC 809C


SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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
MONTEREY PARK, CA 91754
FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310
VISIT DATE: 04/19/2022
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During today’s visit LPA observed that the facility was has full bed rails for all residents. LPA also observed that one resident’s medication was given without been charted in the MAR.

During today’s visit there were deficiencies observed, Title 22 Chapter 6 Regulations are being cited

please see LIC809- D.
Exit interview held. A copy of the report and appeals rights was provide.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2022 09:47 AM - It Cannot Be Edited


Created By: Ngozi Nwaokoro On 04/19/2022 at 12:39 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MIRACLE MILE MANOR RCFE
FACILITY NUMBER: 198603310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2022
Section Cited

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 (h) All medication side effects observed by the facility personnel or reported to the personnel by residents, their authorized representative, significant other, relative, or friend shall be reported to the physician immediately.

(1) There shall be documentation of the date and time the report is made to the physician.
Type B
04/19/2022
Section Cited

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(a) Based the the individuals preadmission appraisal, and subsequent changes to that appraisal, the facility shal provide assistance and care for the resident in those activities of the daily living which the resident is unable to do for him/herself. Postural support may be used under the following condition.
(B) Bed rails that extend the ential lenght of the bed are prohibited except for residents who are currently recieving hospic care and have a hospic care plan that specifies the need for full bed rails.

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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:Michael Cava
LICENSING EVALUATOR NAME:Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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