197609076-8-5-2022-31-AS-NMAN-CT2UPX-20230622154614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 08/05/2022
Date Signed: 08/05/2022 06:34:47 PM

Substantiated

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
06/07/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220607160122

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: 63	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is malodorous.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit to complete an investigation of the above noted allegations. Upon arrival LPA Lacy met staff Alexcis Peralta and explained the purpose of this visit.

It is alleged that the facility smells like urine and poop. Upon arrival in the facility, LPA could smell a strong order of urine throughout the first floor of the facility.
During this visit LPA conducted a physical plant tour at 10:56am. While conducting a physical plant tour, LPA questioned staff #1 (S1) regarding the odor in the facility. S1 responded, “I’ve observed staff cleaning resident’s rooms and changing the linens, I know they are cleaning”. The mattresses have been changed and plastic placed on them. During the physical plant tour, LPA observed the second floor to be free from odor of urine. During the investigation S1 informed LPA the first floor is mainly housing incontinent residents. LPA interviewed the administrator at 12:21pm on 8/5/2022 she confirmed that staff are cleaning rooms and changing linens. Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220607160122

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: 08/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/19/2022 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625Managed Incontinence(d)In addition to Section 87611, General Requirements for Allowable Health Conditions...(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by	1 2 3 4 5 6 7	The administrator will submit to LPA by POC due date an in-service for incontinent residents, and ensure staff transports solied linen to the laundry room as needed.
	8 9 10 11 12 13 14	Based on LPA interviews and observations, the facility failed to ensure that the facility is free from odors of incontinence.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20220607160122

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: 08/05/2022

NARRATIVE

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Staff has a covered trash can where soiled linens are stored throughout the day then transported to the laundry room at the end of the day. Although the facility has a procedure for retaining soiled linens, the odor of urine is present in the facility at the time of the visit. Based on interviews, inspection, and observation. there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUNSTANAITED.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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