197601257-3-16-2022-31-AS-NRED-CCKRDJ-20220316125601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601257
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:56:44 PM

Document Has Been Signed on 03/16/2022 12:56 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELVIN RESIDENTIAL CARE		FACILITY NUMBER:	197601257
ADMINISTRATOR:	REY TABAYOYONG		FACILITY TYPE:	740
ADDRESS:	7737 MELVIN AVE.		TELEPHONE:	(818) 349-6694
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	5	CENSUS: 4	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Rosalie Tabayoyong		TIME COMPLETED:	01:11 PM

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At approximately 11:15 AM on 03/16/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Licensee and disclosed the reason for the visit. LPA and Licensee toured the facility inside and out.

Census: 4 residents, 3 staff

The facility is a single-story building with 3 bedrooms, 2 bathrooms, living room, a garage which serves as a staff office, front yard, and back yard. The facility has a surveillance camera at the main entrance and motion detectors with auditory alarms at all exits. The facility has a fire clearance for 6 non-ambulatory residents and an approved hospice waiver for 1 resident.

At the front, LPA observed an unlocked gate at the eastern sidewalk entrance. Signs regarding the facility’s visitation policy and COVID symptoms were posted at the main entrance. Upon entry, LPA was screened for symptoms of COVID-19 and temperature checked. All staff were wearing surgical masks. Postings for personal rights, confidential complaints, non-discrimination notice, facility license, and Ombudsman contact were visible at the front. LPA also observed signs for the facility’s COVID practices near the kitchen.

Bedrooms: Bedroom #1 and Bedroom #3 were occupied, shared rooms with beds at least 6 feet apart for social distancing. Bedroom #2 is a vacant, private bedroom which the facility can use for isolation purposes. All bedrooms contained a chair, nightstand, lamp, dresser, adequate storage, and beds with adequate bedding.

Bathrooms: LPA observed grab bars around the toilet and shower, non-skid mats, fully stocked liquid soap, a handwashing instruction sign, a small trash can, and personal hand towels in the resident bathroom. Licensee reported that staff monitor provide supervision each time a resident uses the restroom. Staff also provide paper towels as needed. LPA recommended a trash can with a lid for infection control purposes.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELVIN RESIDENTIAL CARE	FACILITY NUMBER: 197601257
	VISIT DATE: 03/16/2022

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Common Areas: Furniture was arranged to accommodate social distancing. 4 residents were observed watching television in the living room during the visit. LPA observed paper supplies and PPE stored in a closet by the resident bathroom.

Garage: LPA observed a garage with an office desk, computer, food storage, water storage, and bathroom. LPA observed no hazards or chemicals.

Kitchen: In the kitchen, LPA observed chemicals and cleaning supplies locked under the sink. Medications were locked near the sink. The kitchen had an adequate supply of perishable and non-perishable food and extra supplies in a cabinet.

Outdoors: LPA and Licensee toured the back yard. All paths were well maintained and free from obstructions or hazards. Gardened areas were in good condition. LPA observed a locked tool shed.

Safety: LPA observed 2 fully charged fire extinguishers in the kitchen. LPA tested smoke detector and carbon monoxide detector in the kitchen, and both were functioning appropriately. At approximately 11:50 AM, LPA measured water temperature in the resident bathroom to be 106.4 degrees Fahrenheit. All emergency exit paths were unlocked and free from debris. Emergency Disaster Plan was posted.

All floors, ceilings, window screens, walls, and furniture were clean and in good condition. The indoor temperature was measured at 73.2 degrees Fahrenheit.

During today's visit, facility is in compliance with Title 22 Regulations, no citations are issued.

Exit interview conducted and copy of the report issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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