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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609672
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:56:52 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/29/2022 03:56 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MELOS CARE HOMEFACILITY NUMBER:
567609672
ADMINISTRATOR:EDWIN PAUL OYASANFACILITY TYPE:
740
ADDRESS:348 W AVENIDA DE LOS ARBOLESTELEPHONE:
(805) 590-6386
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Paul OyasanTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to the facility above to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on This will be the first Annual from their Pre-Licensing visit on 7/23/2021. The LPA was greeted and screened at the door by caregiver, Grace, the Licensee arrived shortly after and the reason for the visit was explained. Entrance interview.

At 9:37 a.m., the 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.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated cabinet under the kitchen sink where knives, sharps, and toxins are locked and inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. Bathrooms were measured for hot water, the first bathroom measured at 102.2 degrees Fahrenheit at 9:27 a.m., and the second bathroom measured at 100.6 degrees Fahrenheit at 9:43 a.m. The Licensee corrected water temperature during visit.

…Report Continued on LIC 809C…

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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: 08/29/2022
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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. The laundry room, cleaning supplies, and chemicals are stored and inaccessible to residents. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents during time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed one (1) resident in the living room watching television. Medications are in a locked cabinet adjacent to the kitchen. Fire extinguisher was observed to be last serviced on 3/2021.

During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Report was previously signed; however, signatures were lost due to a consistency check. Report emailed to Licensee for signatures.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2022 03:56 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2022
Section Cited

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87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care... temperature of not less than 105-degree F and not more than 120-degree F.
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as two (2) out of two (2) facility restroom faucets delivers hot water measured at 102.2 and 100.6 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
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Type B
09/02/2022
Section Cited

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87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services… county fire department or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Based on LPA observation, the licensee did not comply with the section cited above as fire extinguisher was served over a year ago, which poses a potential health and safety risk to persons 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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