197601257-4-3-2025-31-AS-HRAI-DFDV6F-20250403160927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601257
Report Date: 04/03/2025
Date Signed: 04/03/2025 04:10:18 PM

Document Has Been Signed on 04/03/2025 04:10 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELVIN RESIDENTIAL CARE		FACILITY NUMBER:	197601257
ADMINISTRATOR/ DIRECTOR:	REY TABAYOYONG		FACILITY TYPE:	740
ADDRESS:	7737 MELVIN AVE.		TELEPHONE:	(818) 349-6694
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 5		CENSUS: 1	DATE:	04/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Rosalie Tabayoyong, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

NARRATIVE

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At 1:45 PM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Gina Jamilano who granted access to the facility. The staff contacted the Administrator Rosalie Tabayoyong via telephone and LPA explained the purpose of the visit. The Administrator arrived shortly after. 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 single-story 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 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 observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA observed knives and sharps located in kitchen cabinet, to be inaccessible to one (1) out of one (1) resident in care. LPA observed several Lysol disinfectant wipes and other cleaning solution sprays on the top of the kitchen sink and accessible to a one (1) out of one (1) resident in care. 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.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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

FACILITY NAME: MELVIN RESIDENTIAL CARE	FACILITY NUMBER: 197601257
	VISIT DATE: 04/03/2025

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Medications: At 1:55 PM, LPA observed medication being locked in the kitchen cabinet and were inaccessible. a locked office where all residents medications were locked and inaccessible. LPA also observed residents and staff files locked in the garage area and available for review.

Bedrooms: LPA observed 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: The facility has one (1) bathroom. The bathroom contained fully stocked soap, paper towels, trash can, non-skid mats, and grab bars. LPA observed trash cans with tight fitting lids, -Hot water temperature measured at 109.6°F. LPA observed that the bathroom sink is clogged.

Garage: LPA 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. LPA also observed functional washer and dryer in the garage and inaccessible to residents in care.

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

Between 2:15 PM to 3:15 PM, LPA reviewed records of one (1) resident and one (1) staff. Resident and staff records appeared to be complete and updated.

During the interview with one (1) out of one (1) resident, LPA was informed that the facility staff does not provide any milk to the resident without any Physician order. Administrator confirmed that the milk is being withheld from the resident without a Physician order.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

A deficiency was issued during today's visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/03/2025 04:10 PM - It Cannot Be Edited

Created By: Huma Rahimi On 04/03/2025 at 03:47 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELVIN RESIDENTIAL CARE	FACILITY NUMBER: 197601257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(3)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in withhelding milk from one of out one resident without Physician order or resident's consent which which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	The Administrator will conduct in service training on the cited regulation 87468.1 Personal Rights of Residents in All Facilities and provide a staff sign in sheet by POC due date 04/10/2025 and provide copy to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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