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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425149
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:47:25 PM

Document Has Been Signed on 02/12/2024 03:47 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MELOSA, INC.FACILITY NUMBER:
336425149
ADMINISTRATOR:CHRISTOPHER ALCAYDEFACILITY TYPE:
735
ADDRESS:14495 SUSANA CT.TELEPHONE:
(951) 208-4722
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Christopher Alcayde - AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Christopher Alcayde and informed him of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 107.2 degrees. LPA Colvin observed a large amount of boxes and other items stored along the side of the building. LPA Colvin additionally observed that these items blocked the exit door from Resident One's (R1) bedroom to the backyard of the facility. Deficiency cited. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a cabinet in the kitchen, away from residents' reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 ambulatory residents. No exceptions or waivers are present at this time.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is an Administrator present, as evidenced by Administrator being present when LPA Colvin arrived at the facility. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MELOSA, INC.
FACILITY NUMBER: 336425149
VISIT DATE: 02/12/2024
NARRATIVE
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Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that R1 does not have a Physician's Report in their file, but Administrator Christopher Alcayde was able to provide LPA Colvin with a recent physical for R1, which contained all information other than R1's ambulatory status. Since R1 was present at the facility in the common area and LPA Colvin could observe R1 ambulating without assistance from any device, and the only information missing was R1's ambulatory status, LPA Colvin will be issuing a Technical Violation instead of a deficiency for the missing Physician's Report. LPA Colvin additionally observed that the resident files did not contain a recent (within the last year) Needs & Services Plan or Individual Program Plan (IPP) for 3 out of 4 residents: Resident 2 (R2) was last updated 2021, Resident 3's (R3) was last updated 2019, and Resident 4's (R4) was last updated 2020. Deficiency cited. LPA Colvin was unable to interview 3 of 4 of the residents residents during today's inspection as they were all out in the community or asleep.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in the hallway and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Through review of resident files, LPA Colvin confirmed that residents are regularly evaluated by their physician and other medical professionals regularly.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular disaster drills for both earthquakes and fires.

An exit interview was conducted with Administrator Christopher Alcayde and a copy of this report, LIC809D, LIC9102-TV, and appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/12/2024 03:47 PM - It Cannot Be Edited


Created By: Crystal Colvin On 02/12/2024 at 03:21 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MELOSA, INC.
FACILITY NUMBER: 336425149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan: (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 4 resident Needs & Services Plans, which poses a potential health risk to persons in care. LPA Colvin observed that 3 of 4 residents did not have a current Needs & Services Plan or Individual Program Plan (IPP) within the last 12 months.
POC Due Date: 02/26/2024
Plan of Correction
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Administrator agrees to obtain copies of all residents' most recent IPP from Inland Regional Center and update the resident files at the facility. Administrator to provide LPA Colvin with the first page of IPP for each resident to prove correction was made. Plan of Correction due by 2/26/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2024 03:47 PM - It Cannot Be Edited


Created By: Crystal Colvin On 02/12/2024 at 03:37 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MELOSA, INC.
FACILITY NUMBER: 336425149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 doorway, which poses an immediate safety risk to persons in care. LPA Colvin observed that the exit door (from the facility to the backyard) from R1's room was blocked on the outside by boxes and other items.
POC Due Date: 02/13/2024
Plan of Correction
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Administrator agrees to move items away from the door way and provide LPA Colvin with photographic proof of correction. Plan of Correction due by 2/13/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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