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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609672
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:20:04 PM

Document Has Been Signed on 08/28/2023 03:20 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:
08/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Paul OyasanTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 12:45 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Paul Oyasan arrived shortly thereafter.

MEDICATIONS: Medications review began at 1:00 p.m.; medications are centrally stored and locked in a filing cabinet in the dining room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

RECORDS: Residents’ records review began at 2:25 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The following was noted: 4 resident records (S1, S2, S3 , S4) were incomplete. 4 out of 4 resident records (S1,S2, S3, S4) were missing the consent to medical treatment form at the time of record review. S2, S3 and S4 were missing the needs and form and S2 was missing the pre-appraisal form. Administrator was reminded that files need to be completed in a timely manner upon residents admission to the facility.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

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.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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Document Has Been Signed on 08/28/2023 03:20 PM - It Cannot Be Edited


Created By: Elsie Campos On 08/28/2023 at 03:06 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELOS CARE HOME
FACILITY NUMBER: 567609672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited aboveas in 4 out 4 residents were misisng the appropriate consent forms which pose a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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The adminsitrator agreed to the following:
1. Have all resident files updated to show completed consent forms. Provide proof ro CCL no later than 9/1/2023.
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 4 residents were missing the appropriate preadmission appraisal which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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The adminsitrator agreed to the following:
1. Have all resident files updated to show completed preappraisal and needs and services plans. Provide proof ro CCL no later than 9/1/2023.
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
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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