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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 12/27/2021
Date Signed: 12/27/2021 03:26:01 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:68CENSUS: 60DATE:
12/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced case management visit. LPA meet with staff Alexcis Peralta and explained the purpose for this visit.

A physical plant tour was conducted at 11:52am to ensure no immediate health and safety issues were present. No immediate health and safety issues were noted. The facility submitted a Serious Injury Report dated 12/20/21, stating around 8:00am R1 was not in the facility.

LPA requested copies of documents relevant to the incident report at 12:23pm.

During this visit LPA investigated staffing, dementia plan of operation, care and supervision of dementia residents and monitoring of emergency exits. LPA conducted interviews with staff at approximately 12:38pm. LPA interviewed residents at 1:05pm.

Based on interviews, observations and documents obtained LPA has determined that further investigation is required at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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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