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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609672
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:12:51 PM

Document Has Been Signed on 07/01/2025 04:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELOS CARE HOMEFACILITY NUMBER:
567609672
ADMINISTRATOR/
DIRECTOR:		EDWIN PAUL OYASANFACILITY TYPE:
740
ADDRESS:348 W AVENIDA DE LOS ARBOLESTELEPHONE:
(805) 590-6386
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
07/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Edwin Paul OyasanTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 02:16 PM. LPA met with facility staff who contacted the facility Administrator Edwin Paul Oyasan. The Administrator arrived to the facility at 02:23 PM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 02:25 PM the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain knives and other sharp objects. Additionally, this locked cabinet was observed to contain cleaning supplies. LPA informed the Administrator that toxins may not be stored in the same storage as kitchen equipment or utensils. Administrator agreed to remove the chemicals and store the items in an alternate locked storage. LPA observed a fire extinguisher mounted on the wall to be serviced on 06/03/2025. The kitchen contained a locked cabinet that contained resident medications.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELOS CARE HOME
FACILITY NUMBER: 567609672
VISIT DATE: 07/01/2025
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COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. The dining area was observed to be equipped with adequate seating for resident use. The hallway contained storage closets which contained extra linens for resident use and additional care supplies. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 02:52 PM and were functional at the time of the visit. During the fire alarm test LPA observed the facility’s hallway fire door to fail to close. LPA informed the Administrator that this is a zero tolerance violation of the facility’s fire clearance. LPA informed the Administrator that an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/01/2025). The Administrator agreed to call a repairman to make appropriate repairs to the fire door. All exits in the facility were observed to contain functioning auditory alarms.

BEDROOMS: There are four (4) bedrooms in the facility; one (1) is a dual occupancy resident room and three (3) are single occupancy resident rooms. LPA and the facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #3 & 4 contained a direct exit to the outdoors of the facility.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Both bathrooms contained locked under sink storage cabinets that contained resident grooming supplies. Grab bars were observed in all resident showers and near all resident toilets all were properly secured. The water temperature was measured to be between 108.0 and 110.7 degrees Fahrenheit, which is within the range required by regulation.

OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELOS CARE HOME
FACILITY NUMBER: 567609672
VISIT DATE: 07/01/2025
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GARAGE: LPA observed the garage to be inaccessible to clients in care. LPA observed the garage to contain the facility’s emergency food supplies, the facility’s washer and dryer, and locked storage for laundry chemicals. Additionally, the garage was observed to be utilized as the Administrator’s office.

INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility.

Due to time constraints an LPA will return at a later date to conduct staff interviews, conduct a record/medication review, review the facility’s emergency disaster plan/infection control plan, and to obtain copies of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 04:12 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/01/2025 at 03:47 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2025
Section Cited
CCR
87555(b)(24)

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87555 General Food Service Requirements
(b) The following...shall apply:
(24)... toxic substances shall not be stored...where kitchen...utensils are stored. This requirement is not met as evidenced by:
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Administrator agreed that licensee will relocate the chemicals to a seperate locked storage area no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as knives and other sharp objects were stored alongside toxins and cleaning chemicals in a locked under-sink storage cabinet located in the kitchen which poses an immediate health risk to clients in care.
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Type A
07/02/2025
Section Cited
CCR87202(a)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance...
This requirement is not met as evidenced by:
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The administrator agreed that licensee will ensure the fire door remains closed until appropriate repairs can be completed. Administrator agreed to submit proof of the fire door functioning properly to CCLD.
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Based on observation the licensee did not comply with the section cited above as the facility's fire door failed to close during a test of the facility's smoke alarms which poses an immediate safety risk to clients 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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