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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800005
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:17:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250106134624
FACILITY NAME:GEMILAN HOME CARE CENTERFACILITY NUMBER:
565800005
ADMINISTRATOR:MELANIE MARINFACILITY TYPE:
735
ADDRESS:4310 CASPER COURTTELEPHONE:
(805) 488-9424
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 6DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melanie Marin, Administrator and Delia D Cafuir, Licensee TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee did not ensure facility was maintained clean and in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi along with Quality Assurance Specialist (QAS) Tri-Counties regional center Katy Robison conducted an unannounced initial complaint visit to this facility. At 9:40 a.m., the LPA and QA met with staff and explained the reason for the visit. At 10:00 a.m., Administrator Melanie Marin arrived at the facility. During the time of the visit, the LPA met with the Licensee.

Between 9:46 a.m. and 1:45 p.m., the LPA conducted interviews with the Administrator, Licensee and three (3) residents. At 10:06 a.m., the LPA conducted a physical plant tour. At 1:36 p.m., the LPA requested and obtained copies of pertinent documents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20250106134624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GEMILAN HOME CARE CENTER
FACILITY NUMBER: 565800005
VISIT DATE: 01/10/2025
NARRATIVE
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Regarding the allegation: Licensee did not ensure facility was maintained clean and in good repair. During todays visit, the LPA observed the following: spider webs throughout the facility, restroom door with chipped paint, a hole in the wall in Resident #1’s (R1’s) room and loose wires in R1’s room. Additionally, the LPA observed R1’s dresser in bad condition. The LPA had a conversation with the Administrator regarding the LPAs observations. The Administrator stated that she will ensure that the facility will remain clean and in good repair. Based on observations, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250106134624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GEMILAN HOME CARE CENTER
FACILITY NUMBER: 565800005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Administrator stated that the facility will be deep cleaned, and repairs will be done. The Administrator stated that she will send proof to the LPA by 01/24/2025.
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Based on observations, the licensee did not comply with the above cited section as spider webs, a hole in the wall, and chipped paint was observed which poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250106134624

FACILITY NAME:GEMILAN HOME CARE CENTERFACILITY NUMBER:
565800005
ADMINISTRATOR:MELANIE MARINFACILITY TYPE:
735
ADDRESS:4310 CASPER COURTTELEPHONE:
(805) 488-9424
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 6DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melanie Marin, Administrator and Delia D Cafuir, Licensee TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee evicted resident in retaliation.
Licensee did not ensure facility was free from pests.
Staff due not ensure planned activities are provided to clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi along with Quality Assurance Specialist (QAS) Tri-Counties regional center Katy Robison conducted an unannounced initial complaint visit to this facility. At 9:40 a.m., the LPA and QA met with staff and explained the reason for the visit. At 10:00 a.m., Administrator Melanie Marin arrived at the facility. During the time of the visit, the LPA met with the Licensee.

Between 9:46 a.m. and 1:45 p.m., the LPA conducted interviews with the Administrator, Licensee and three (3) residents. At 10:06 a.m., the LPA conducted a physical plant tour. At 1:36 p.m., the LPA requested and obtained copies of pertinent documents.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250106134624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GEMILAN HOME CARE CENTER
FACILITY NUMBER: 565800005
VISIT DATE: 01/10/2025
NARRATIVE
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Regarding the allegation: Licensee evicted resident in retaliation. It was alleged that the Administrator and Licensee evicted Resident #1 (R1) due to retaliation as R1 and R1’s family voiced concerns about the cleanliness of the facility and other issues at the facility. During the initial visit, the LPA spoke with the Administrator regarding R1’s eviction notice. The Administrator stated that the eviction notice was due to R1’s not following house rules and R1 needing a higher level of care. The LPA explained to the Administrator that the eviction notice is not lawful as the reason given to R1 were not valid. The LPA explained that the Administrator would have to rescind the eviction notice. The Administrator stated that the eviction notice will be rescinded. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation as R1 is still residing at the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Licensee did not ensure facility was free from pests. It was alleged that the facility has issues with ants in the home. During todays visit, the LPA did not observed ants or other pests in the home. The Administrator stated that staff clean daily but that she will have staff deep clean the facility and spray for insects and ants. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff due not ensure planned activities are provided to clients in care. Interview conducted with Administrator revealed that activities include bingo, puzzles, walking around the block, and outings to the mall and parks. Resident interviews conducted revealed that there are some activities provided such as board games, and outings. The LPA observed an unfinished puzzle and board games in the living area. The LPA also observed exercising equipment such as a treadmill and exercising bicycle in the living area and backyard. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5