197609076-4-18-2022-31-AS-LQLY-CDM34Z-20220418175554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 04/18/2022
Date Signed: 04/18/2022 05:56:57 PM

Document Has Been Signed on 04/18/2022 05:56 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELROSE VILLAS		FACILITY NUMBER:	197609076
ADMINISTRATOR:	VERGARA, KANDICE		FACILITY TYPE:	740
ADDRESS:	823 N POINSETTIA PLACE		TELEPHONE:	(323) 746-7840
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	68	CENSUS: 62	DATE:	04/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) LaQueena Lacy arrived to the facility at 11:10am to conduct a One (1) year Required Infection Control visit. LPA meet with Alexcis Peralta and explained the purpose of this visit. A tour of the physical plant was conducted at 11:21am and the following was observed: The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located at the entrance of the facility at the front desk equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask, and sign in sheet at the time of visit. The facility has an approved mitigation plan on file. The Facility is licensed for a capacity of 68 non-ambulatory residents, which twenty (20) may be bedridden and hospice waiver for twenty (20) residents. Kitchen: At 11:23am the kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in the refrigerator, freezer, and pantry. Food was properly labeled and stored. LPA observed a variety of fresh fruits, vegetables, meat, dry cereals, and desserts during the time of inspection. Sharps were observed to be stored in the kitchen which is closed off and inaccessible to residents. Fire extinguisher observed to be stored near the exit door i n the kitchen and on the first and second floor with a service tag dated 04/13/2022. The emergency food is stored and observed locked at 11:34am in an outdoor shed behind the facility. All trash can contain lids. Continue on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2022

NARRATIVE

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Bedrooms: At 11:36am between 12:26pm LPA observed twelve (12) bedrooms to be appropriately furnished with sufficient lighting. All bedrooms observed to be clean and clear from obstruction. LPA observed appropriately bed linen and comforters on all beds. (blank) are single occupancy and (blank) are shared rooms.

Bathroom: At 11:36am LPA observed (12) bathrooms to be clean and in proper operation. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats or strips located in the shower area. The water temperature measured range between 110.7 - 112.7 degrees Fahrenheit. Hand towels are not shared. Trash can contain lids.

Medications: LPA observed the medication room at 12:28pm on the second floor near the elevator label activity locked and inaccessible to residents. The facility first aid kit and manual located on the first floor at the receptionist desk. LPA also observed extra first aid supplies in the medication room in a cabinet. LPA observed the activities stored in a closet in the medication room, locked and storing board games, bingo, basket and soccer balls, and decoration supplies.

Storage rooms: LPA observed a storage room on the first floor to be storing extra linen and comforters. Second floor contain a storage closet for janitorial supplies, cleaning solutions and toxins observed to be locked.

Backyard: At 12:43pm LPA observed the outside and surrounding area of the facility to be clean and clear from obstruction. The facility has cabana with table and chairs for lounge on the side of the facility open outdoor area, and tables and owning for seating in the front patio area of the facility. The facility has five (5) plastic sheds located on the side of the facility behind the sister facility. One shed is used for maintenance tools and supplies, two (2) sheds are used for emergency food supplies, water and food supply storage for extra food, and (2) sheds are used for incontinent supply, overflow of incontinent supplies and PPE. All sheds were observed to be locked and inaccessible to residents. At 12:57pm the laundry room was observed to be clean and clear from obstruction and inaccessible to residents.

Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2022

NARRATIVE

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Living, dining room and common areas: At 12:51pm LPA observed to be appropriately furnished with tables
and chairs and adequate lighting. The facility maintains a comfortable temperature at 75 degree Fahrenheit.
Observed to be neat and clean.

At 3:00pm the fire alarm system was tested and observed to be working, it is hard wired throughout facility.
The carbon monoxide detector is located near room 112 tested and to be operational,
No Deficiencies cited, exit interview conducted, and copy of this report and appeal rights issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC809 (FAS) - (06/04)

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