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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 564700047
Report Date: 08/23/2024
Date Signed: 08/23/2024 09:17:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/23/2024 09:17 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:MELOS HOME CAREFACILITY NUMBER:
564700047
ADMINISTRATOR/
DIRECTOR:		EDWIN OYASANFACILITY TYPE:
300
ADDRESS:1051 QUASAR CTTELEPHONE:
(805) 267-6865
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: CENSUS: DATE:
08/23/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Edwin OyasanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Enforcement Analyst (EA), Joshua Rarela, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of a Biennial visit. The EA met with Home Care Organization (HCO) representative named above.

During the inspection, the EA observed the posting of the license and operating business hours which show the business operates from Monday through Friday, 8AM-5PM. EA reviewed the personnel records for licensee, staff and Home Care Aides. Furthermore, EA reviewed the HCO’s business records including training agenda, abuse reporting incidents, current designee and insurance requirements.

During today’s visit, EA informed the licensee of the deficiencies found and explained they would be noted on the HCS809-Ds. In addition, the HCO representative was provided a copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2024 09:17 PM - It Cannot Be Edited


Created By: Joshua Rarela On 08/23/2024 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: MELOS HOME CARE
FACILITY NUMBER: 564700047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
1796.45(a)
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An individual hired to be an affiliated home care aide…shall be submitted to an examination 90 days prior to employment or within seven days after employment to determine that the individual is free of active tuberculosis disease…an affiliated home care aide whose test for tuberculosis infection is negative shall be required to undergo an examination at least once every two years.
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This requirement is not met as evidenced by:

Review of records showed that Reference #5 had an expired TB test.
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Type B
09/23/2024
Section Cited
1796.44
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A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section...a minimum of five hours of entry-level training prior to presence
with a client, as follows: two hours of orientation training regarding his or her role as caregiver and… three hours of safety training, including basic safety precautions…a minimum of five hours of annual training.
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This requirement is not met as evidenced by:

EA was unable to review the training records as the licensee did not have it stored on-site although the licensee stated that they are current.
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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.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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