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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609672
Report Date: 10/28/2024
Date Signed: 10/28/2024 05:08:30 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
07/17/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230717142820
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: 5DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Edwin Paul OyasanTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff did not provide emergency personnel with resident's proper documentation.
Staff accepted a resident into the facility requiring a higher level of care.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced for a subsequent complaint visit to deliver the findings for the allegations listed above. The LPA met with Administrator Paul Oyasan and explained the reason for the visit.

On 07/26/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial complaint visit to investigate the above allegations at 3:20 p.m. The LPA met with Administrator Paul Oyasan and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 3:25 p.m., interviewed resident at 3:38 p.m., interviewed administrator at 4:03 p.m., and collected pertinent documents at 4:10 p.m.

Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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-20230717142820
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: MELOS CARE HOME
FACILITY NUMBER: 567609672
VISIT DATE: 10/28/2024
NARRATIVE
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Staff did not provide emergency personnel with resident's proper documentation.
On the allegation that staff did not provide emergency personnel with resident’s proper documentation, it is the concern of the reporting party (RP) that the staff at the facility had no information regarding the resident (R1) when EMT personnel arrived to provide care for the resident and were unable to get any information regarding the resident’ medical history or contact information for R1. On 07/26/2023 LPA Campos interviewed the administrator, and the administrator stated that when EMT arrived to provide care to R1 and asked for R1’s personal information, the administrator gave the EMT personnel a copy of the Physician’s Report. Furthermore, the Administrator stated that on a previous EMT visit, the Administrator gave by mistake the original R1’s personal information, so the administrator did not have a copy. The Administrator stated that they gave the EMT, R1’s Conservator’ card and telephone number. On 10/11/2024, LPA Urena interviewed the Administrator, and the administrator stated that they did not recall why R1 was taken to the hospital, and that the protocol when EMT’s arrive to provide care, staff are to give them the residents’ personal contact information (LIC 601), the resident’s physician’s report, and centrally stored medication list, however these documents were not provided to the EMT personnel on 07/16/2023. The physician’s report obtained by LPA Urena was incomplete as it stated to see ‘attachment’ for the diagnosis, however, the attachment was not included/attached to the physician’s report. Staff interviewed stated that they could not exactly remember if the requested documents were available at the time R1 was taken to the hospital. LPA Urena was unable to interview the reporting party, and R1’s Conservator.

Based on the information obtained through interviews, the staff did not provide the EMT personnel with the R1’s medical history, and medication information. Therefore, the allegation that staff did not provide emergency personnel with resident’s medical and history documentation, is deemed Substantiated at this time.

Continues on LIC 9099C...
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230717142820
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: MELOS CARE HOME
FACILITY NUMBER: 567609672
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87458(a)
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87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a full medical assessment, signed by a physician. This requirement is not met as evidenced by:
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The Administrator has agreed to do the following: To keep full packet of Emergency Documents in case of emergencies and to hand to EMT at request, review regulation cited and send a statement of understanding to LPA via email by 11/01/2024 at COB.
Administrator provided proof of correction at time of the visit.
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Based on records review the licensee did not comply with the section cited above as one (1) out of the five (5) resident records reviewed did not have a complete Physicians' Report (LIC 602), which poses a potential health, safety or personal rights 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230717142820
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: MELOS CARE HOME
FACILITY NUMBER: 567609672
VISIT DATE: 10/28/2024
NARRATIVE
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Pg. 3
Staff accepted a resident into the facility requiring a higher level of care.
On the allegation that staff accepted a resident into the facility requiring a higher level of care, it is the concern of the reporting party (RP) that (R1) was extremely ill and was taken to the Intensive Care Unit (ICU) on the day EMT transported R1 to the hospital. On 07/26/2023, LPA Campos interviewed the Administrator, and the administrator stated that facility staff did everything for R1: Feeding, medications, eyedrops, vitamins, bathing, incontinent care. Staff stated that they would crush the medication and would put in in R1’s food. The LPA did not receive or found doctor’s orders for medication to be crushed and put in R1's food. R1 was not receiving hospice services while residing at the facility. The Administrator stated that the first time R1 was taken to the hospital, it was due to pneumonia. Administrator did not know why R1 was taken to the hospital the second time. On 10/11/2024, LPA Urena interviewed the Administrator and the administrator stated that R1 was receiving Home Health Services, PT (physical therapy) for mobility and transferring from chair to bed and vice versa. . Per Home Health communication with Administrator, R1 was seen by nurse with weekly visits from 12/28/22- 7/16/23 totake vitals, and was seen twice a week for physical therapy from 1/18/23- 2/22/23. On 10/11/2024, LPA Urena reviewed R1’s physician’s report dated 12/26/2022, and discharge papers from Health Care Center. Diagnosis Intestinal fibrosis, dysphasia, emphysema. R1 was to be admitted to facility with 24-hour caregiver services. Per staff interviews R1 was not receiving 24-hr, or one-to-one care. Furthermore, staff stated that home health was coming to check vitals and check sugar levels of R1. Staff does not recall if R1 was receiving PT for transferring from chair to bed and bed to chair.

Based on the information obtained through record review, R1 required 24-hour care, and one person assist at all times. Therefore, the allegation that staff accepted a resident into the facility requiring a higher level of care, is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230717142820
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: MELOS CARE HOME
FACILITY NUMBER: 567609672
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
HSC
1569.72(1)
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1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (1) The resident requires 24-hour, skilled nursing or intermediate care. This requirement is not met as evidenced by:
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The Administrator has agreed to do the following: Review regulation cited and send a statement of understanding to LPA via email by 11/01/2024 at COB.
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Based on records review the licensee did not comply with the section cited above as R1 required 24 hour care, and administration of medication.
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5