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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:38:04 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210416123631
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: 61DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Alexis Peralta - Assistant AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with Assistant Administrator Alexis Peralta and explained the reason for the visit.

On 04/20/21, then LPA Margaryan conducted the initial complaint visit. During her visit, LPA Margaryan conducted physical plant tour at 11:30 AM, interviewed administrator and staff between 9:15 AM to 10:30 AM, requested facility documents at 11:00 AM.

It was alleged that the resident #1 (R1) was admitted to the hospital where R1 was observed to have four (4) unstageable pressure injuries. The injuries were located on R1’s lower back, buttock, hip and shoulder.
The investigation of the allegation was conducted by the Investigator Dennis Douglas from the Investigation Branch of the Community Care Licensing Division.
(continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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 31-AS-20210416123631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
VISIT DATE: 02/17/2022
NARRATIVE
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(continued from LIC 9099)

During Course of Investigation on 05/12/2021, Investigator Douglas spoke with the Administrator and other facility staff. On 07/07/21 between 4:00 PM to 5:00 PM, Mr. Douglas spoke with additional facility staff. Interviews revealed that they observed the pressure injuries in between February and March of 2021. Due to lack of medical insurance coverage the facility was unable to obtain adequate medical treatment for R1’s pressure injuries and the conditions of the wounds were worsened. Staff indicated that R1’s pressure injuries were not healing due to R1 not eating well and R1's declining health condition. Staff admitted that on 02/21/2021 R1 was sent to the hospital due to developing Stage 3, Stage 4, and Unstageable pressure wounds.

Then LPA Margaryan's review of the facility documents and hospital medical records revealed that R1 was admitted to the facility with the Unstageable pressure injuries which required assistance of a medically skilled professional. Due to the problems with R1’s medical coverage, R1 was unable to obtain required medical care. Subsequently, the conditions of the pressure injuries got worse and R1 developed prohibited health condition. While at the hospital, due to R1’s declining health conditions, the pressure injuries were not healing. R1 was discharged from the hospital on 03/12/21. Despite the knowledge of the Administrator and staff that upon R1 had pressure injuries upon discharge and required higher level of care, they accepted R1 back. R1 was re-admitted to the hospital on 05/04/2021 at which time the pressure injuries got even worse.

Based on interviews and record review it was concluded that the facility admitted and retained a resident that required an assistance from the appropriately skilled medical professionals. Additionally, due to neglect in required incidental medical care R1 developed prohibited health condition while in care of the facility. Moreover, R1 was readmitted back to the facility when R1 requires higher level of care. Therefore, the allegation is SUBSTANTIATED at this time

Citation issued. Appeal rights discussed and given

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20210416123631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
87615(a)(1)
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Prohibited Health Condition (a) Persons who require health services for or have a health condition including, but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Assistant Administrator agreed to review regulations related to prohibited and restricted health conditions and send a written statement of understanding to CCL. Administrator and staff will complete a training on pressure injuries and proof of training will be sent to CCL on or before the POC date
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Based on interview and record review, the licensee did not ensure that R1 was not retained with a Stage 3 or 4 pressure injury and received proper treatment of the pressure injury, which posed an immediate health and safety risk to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210416123631

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: 61DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Alexis Peralta - Assistant AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not ensure that resident was adequately fed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with Assistant Administrator Alexis Peralta and explained the reason for the visit.

On 04/20/21, then LPA Margaryan conducted the initial complaint visit. During her visit, LPA Margaryan conducted physical plant tour at 11:30 AM, interviewed administrator and staff between 9:15 AM to 10:30 AM, requested facility documents at 11:00 AM.

It was noted that resident #1 (R1) had lost 16 lb over the past 4 weeks while at this facility.

Overall Interviews revealed that R1’s physical condition and health was declining. R1 was refusing to eat and not taking other supplements such as ensure. Staff indicated that although R1 was refusing to eat, R1 did not lose significant amount of weight within 4 weeks. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210416123631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
VISIT DATE: 02/17/2022
NARRATIVE
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(continued from LIC 9099-A)

On 02/21/2021 R1 was sent to the hospital for malnutrition and pressure injuries. Upon review of facility records conducted on 05/21/2021, LPA did not observe any information to verify that R1 suffered a significant weight loss.

Due to absence of supporting documents and based on the information revealed from interviews, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5