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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425149
Report Date: 04/14/2022
Date Signed: 04/14/2022 02:58:10 PM

Document Has Been Signed on 04/14/2022 02:58 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MELOSA, INC.FACILITY NUMBER:
336425149
ADMINISTRATOR:CHRISTOPHER ALCAYDEFACILITY TYPE:
735
ADDRESS:14495 SUSANA CT.TELEPHONE:
(951) 208-4722
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Remedios Pascua, CaregiverTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA met with Caregiver Remedios Pascua. LPA identified himself and was granted entry and toured the facility. Present in the facility during time of visit were 3 clients, with 1 at their day program. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Ms. Alcayde. Caregiver May Alcayde arrived at the facility.

During an inspection of the staff roster, LPA did not find Caregiver Remedios Pascua on the staff roster printed from Guardian. LPA was able to find that Ms. Pascua does have a fingerprint clearance; however, they are not associated to the facility. LPA issued a Technical Violation in reference to this incident.
During the inspection, LPA observed the following deficiency:
  1. Medication cabinet not properly secured by a lock

LPA issued a Type B citation in reference to the observation made during the visit per Title 22. An exit interview was conducted and a copy of this report along with copies of the LIC809-D, LIC9102 and Appeal Rights were discussed with and provided to Ms. Alcayde.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 02:58 PM - It Cannot Be Edited


Created By: Jesse Gardner On 04/14/2022 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MELOSA, INC.
FACILITY NUMBER: 336425149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of the medicine cabinet being secured by a nylon rope that was easily bypassed, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee agrees to update the lock, and provide staff training on the cited regulation and provide proof of such via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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