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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 08/05/2022
Date Signed: 08/05/2022 06:33:25 PM


Document Has Been Signed on 08/05/2022 06:33 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 VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:68CENSUS: DATE:
08/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the faxcility on 8/5/2022 at 10:41am to conduct 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 10:56am 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 7/29/2022 regarding resident #1 (R1) not in his room or located on the facility property.

LPA requested documents relevant to the investigation at 11:26am. To investigate this incident, LPA Lacy interviewed staff #1 (S1) at 11:32am which revealed that staff conducted rounds at 10:30am and R1 was present at the facility. At approximately 12:00am staff conducted rounds and R1 was not present in the room, staff began to check the facility grounds and observed the exit gate on the left side of the building open and the cords connected to the egress gate was disconnect and pulled from the gate. Law enforcement was contacted and a report (7A21-W2) was completed. During the investigation LPA observed a ring camera located on the fence facing the exit gate, per S1, the ring camera was being charged at the time R1 exited the facility. Staff was not sure who and how the exit was monitored while the camera was charging. LPA tested the egress gate to find that the alarm was operational and functional at the time of the visit. Upon document review it was noted that R1 has Dementia and is unable to leave the facility unassisted. LPA interviewed Administrator at 12:21pm, who explained about their future plans to have better monitoring system for Dementia Resident. However, staff and Administrator were able to explain what actions they are taking to ensure health and safety of dementia residents. Based on interviews, inspection, observation and record review, It was concluded that.

Continued on LIC809C

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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: 08/05/2022
NARRATIVE
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The facility staff failed to provide required care and supervision to Dementia resident.

Facility did not ensure that the monitoring system on all exit doors are functioning and being monitored properly.

Exit interview was conducted with the S1, who was informed that since December 2021 they have at least 2 incidents in which due to neglect in care and supervision, dementia residents were able to leave the facility unassisted.

On addition LPA Lacy informed S1 that AWOL of Dementia resident is posing an immediate health and safety hazard to the resident. Therefore, immediate Civil Penalty of $500.00 will be assessed at the time of this visit.

No other immediate health and safety hazard is noted during this visit.

Exit interview was completed, appeal rights were discussed and a copy of report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/05/2022 06:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2022
Section Cited

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87705 Care of Persons with Dementia.(j) The licensee shall have an auditory device or other staff...(k) The following initial and continuing requirements must be met...(8) Delayed egress devices shall not substitute for trained staff...This requirement was not met as evidenced by:
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Based on interviews with (S1), the facility failed to ensure that R1 did not leave the facility unassisted. This poses an immediate health and saftey risk to residents in care.
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Type A
08/06/2022
Section Cited

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87464 Basic Services (d)A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…
This requirement was not met as evidenced by:
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Based on interviews and observation of R1s physician report and pre appraisal, the facility failed to met R1 needs. This poses an immediate health and saftey 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: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3