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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601257
Report Date: 05/18/2024
Date Signed: 05/18/2024 12:46:35 PM


Document Has Been Signed on 05/18/2024 12:46 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
Lookup Error,
, CA



FACILITY NAME:MELVIN RESIDENTIAL CAREFACILITY NUMBER:
197601257
ADMINISTRATOR:REY TABAYOYONGFACILITY TYPE:
740
ADDRESS:7737 MELVIN AVE.TELEPHONE:
(818) 349-6694
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:5CENSUS: 1DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Rey TabayoyongTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on
05/18/2024. LPA was met by Administrators Rey Tabayoyong and Rosalie Tabayoyong and explained the purpose of the visit. The facility is licensed to serve five (5) residents over the age of 60, of which five (5) may be non-ambulatory and has a hospice waiver approved for one (1).

LPA OBSERVATIONS: The facility is a two-story dwelling located on a residential street and consists of three (3) resident bedrooms, one (1) bathroom, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory devices on entry of door to be operational, sliding door and exits.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to one (1) out of one (1) resident in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to one (1) out of one (1) resident in care. Kitchen sink water temperature was measured at 116.5 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 69-degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



SEE 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: 323-981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: MELVIN RESIDENTIAL CARE
FACILITY NUMBER: 197601257
VISIT DATE: 05/18/2024
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Resident Rooms 1-3: LPA Ramirez inspected three (3) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. Bedroom #1 is private and bedrooms 2 & 3 are shared.

Bathrooms 1: Water temperature bathroom was within 105- 120 degrees F.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

Garage: PA Ramirez observed emergency water and extra PPE/linens, and toiletry items in this area. Access to garage was observed to be inaccessible to one (1) out of one (1) resident in care.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last fire drill was conducted on 04/20/24. LPA Ramirez observed a First Aid kit in kitchen cabinet.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Rosalie Tabayoyong with an expiration date of 11/24/2022. LPA Ramirez observed proof of submission for renewal of Administrator’s Certificate. LPA Ramirez will issue Technical Advisory. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Resident Records: One (1) resident record was reviewed.

Liability Insurance & Infection Control Plan: Facility will send proof of liability insurance within 7 calendar days. Facility will send infection control plan within 7 calendar days. LPA Ramirez will issue two (2) technical advisories.




Exit interview was conducted. No deficiencies cited today. A copy of this report, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: 323-981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
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