567609672-7-23-2021-29-AS-MGCZ-C57NQS-20210723104025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609672
Report Date: 07/23/2021
Date Signed: 07/23/2021 12:31:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELOS CARE HOME		FACILITY NUMBER:	567609672
ADMINISTRATOR:	EDWIN PAUL OYASAN		FACILITY TYPE:	740
ADDRESS:	348 W AVENIDA DE LOS ARBOLES		TELEPHONE:	(805) 590-6386
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	07/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jenny Grace Jungco-Caregiver		TIME COMPLETED:	11:00 AM

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to conduct a Required Annual inspection with a focus on Infection Control. LPA was greeted at the door by Caregiver Jenny Grace Jungco. LPA called Administrator, but said she was nowhere near facility and stated Caregiver Jenny could sign for today's report. At this time, LPA explained the reason for the visit to both Administrator and Caregiver.

At 9:23am, LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed a sufficient supply of perishable and non-perishable foods and dried goods stored in the pantry. Emergency food supply was stored in the garage. LPA did not observe any cleaning supplies stored in the kitchen. LPA observed sharp objects and knives were stored in a cabinet by the sink. Medications were stored in locked cabinet in the dining room.

LPA observed all bedrooms to be set up with a bed, night stand, chest of drawers and closet space. All rooms have overhead lighting and ceiling fans. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured at 109.4 degrees Fahrenheit.

The common areas were appropriately furnished, and lighting was adequate at the time of the visit. At 9:37am, LPA observed two (2) residents sitting in living room having breakfast and watching television. LPA observed wired smoke and carbon monoxide detectors throughout the facility. One (1) fire extinguisher located in the kitchen last serviced on March 26, 2021.

Continued on LIC 809c

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELOS CARE HOME	FACILITY NUMBER: 567609672
	VISIT DATE: 07/23/2021

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Continued from LIC 809

LPA observed a 30 day supply of PPE at the facility. CCLD PINs were posted at facility for both residents and visitors to easily read. LPA observed hand washing signs and cough/sneezing etiquette signs posted throughout facility.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview was conducted. Copy of report was issued via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

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