567609672-8-9-2023-29-AS-ECAS-CUJUUQ-20230809155354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609672
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:54:19 PM

Document Has Been Signed on 08/09/2023 03:54 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 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: 4	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Paul Oyasan		TIME COMPLETED:	04:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 12:00 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Paul Oyasan arrived shortly thereafter.

The LPA and the Administrator began the tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 12:15 p.m. Knives and cleaning supplies stored under the kitchen sink were observed to be accessible at the time of visit. Staff was unable to lock the cabinet as the lock was broken. The LPA additionally observed a bag on a chair at the dining room table that contained accessible over the counter vitamins and supplements. It was indicated by the administrator that it belonged to staff. LPA advised the administrator that any over the counter medications, supplements and vitamins do need to remain locked and inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water temperature in the kitchen measured at 117.5 degrees F at 12:29 p.m. The facility has an attached garage that is accessible through the kitchen, the garage contains a staff break area, facility office, additional refrigerator with perishable foods, additional nonperishable food supply,cleaning supplies, emergency water and food supply and laundry appliances. The garage was locked at the time of the visit.

COMMON AREAS: Living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is covered with a screen and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested at 12:45 p.m. and operational at the time of the visit. The fire extinguisher located in the kitchen was fully charged and last serviced September 1, 2022. The LPA observed required postings throughout the common space.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: 08/09/2023

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BEDROOMS/BATHROOMS: The LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated resident rooms one shared and three private bedrooms. There was a linen closet in the hallway with extra towels and linens. There are two resident bathrooms, the resident bathroom in the hallway was observed to be in need of cleaning as toilet bowl was soiled and toilet paper holder was broken. Bathrooms were observed to have grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway bathroom at 115.8 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted and exit is free of obstructions.

RECORDS: Personnel records were observed to be incomplete, not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The following was noted: 2 out of 4 staff records (S1, S2) were missing and unavailable. 2 out of 4 staff records (S3, S4) were incomplete at the time of record review. LPA was unable to verify required training hours for 4 out of 4 staff (S1, S2, S3, S4). 3 out 4 staff were not associated to the facility (S1, S2, S3). Civil penalties assessed.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/09/2023 03:54 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: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above 3 out of 4 staff were not cleared or associated to the facility (S1, S2, S3) which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Adminsitrator agreed to the following: 1. Associate all working staff to the facility and notify CCL no later than 8/10/2023. Civil Penalties Assessed.

Type A

Section Cited

CCR

87705(f)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as knives, sharps and cleaning supplies were observed to be unlocked under the kitchen sink and and over the counter supplements accesssible on dining room table chair which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to the following: 1. Replace lock to cabinet or relocate and lock accessible items and lock up accessible over the counter supplements. Notify CCL no later than 8/10/2023.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/09/2023 03:54 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: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above the resident bathroom in the hallway was unkempt which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Adminsitrator agreed to the following: 1. Clean resident bathroom and fix toilet paper holder and provide proof to CCL no later than 8/10/2023.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 2 out 4 staff files were incomplete (S3, S4) and 2 out 4 staff files were missing (S1, S2) which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Adminstrator agreed to the following: 1. Ensure that each staff has a completed staff file containing all documents required per Title 22 regualtions. Provide proof to CCL no later than 8/18/2023.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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