197609076-5-17-2023-31-AS-NMAN-CT3UEK-20230623153117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:12:59 PM

Unsubstantiated

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
04/08/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220408145205

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: 59	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	12:06 PM

ALLEGATION(S):

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Facility has insufficient staffing for the residents.
Staff do not provide adequate supervision to the residents.
Residents are smoking in non smoking areas.
Facility is operating beyond the terms and conditions of the license.
Staff do not properly maintain the facility .

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit to deliver findings on 05/17/2023. Upon arrival LPA LaQueena Lacy met staff Alexcis Peralta and explained the purpose of this visit.

#1. Facility has insufficient staffing for the residents.

It is alleged that after 10pm there were no staff at the facility to watch the residents. To investigate the above allegation, on 08/10/2022 LPA requested documents relevant to the investigation at 3:38pm. LPA interviewed staff and resident on 08/10/2022 at approximately 2:18pm and 01/11/2023 at approximately 2:15pm- 3:50pm. Interviews with six (06) out of six (06) residents confirm that at least two (02) staff members work at night, and staff is available when they need assistance. Interviews with staff confirm that managers are on call 24hours and cover shifts when needed.
Continued on 9099C.

Unsubstantiated

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: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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 4

Control Number 31-AS-20220408145205

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: 05/17/2023

NARRATIVE

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During the investigation LPA observed a personnel report that identifies (02) staff members scheduled from 2:30pm-10:30pm and 10:30pm-6:30am. Based on interviews, observations and record review, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

#2. Staff do not provide adequate supervision to the residents.

It is alleged that residents are in a restricted area unsupervised. To investigate the above allegation, LPA interviewed residents and staff on 08/10/2022 at approximately 2:18pm and 01/11/2023 at approximately 2:15pm- 3:50pm. Interviews with six (06) out of six (06) residents confirm that the facility provides supervision by staff and managers. Interviews with staff determined that they have some residents that are able to leave the facility unassisted and come and go with no restrictions. Residents that require supervision are monitored and not allowed in any areas outside of the facility gates without staff assistance. During the investigation, LPA observed codes to enter or exit the interior facility grounds which is accessible to all residents and did not observe any residents in the exterior grounds of the facility that is inaccessible to resident. Based on interviews and observations there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

#3. Residents are smoking in non-smoking areas.

It is alleged that residents are in a restricted area smoking. To investigate the above allegation,

Continued on 9099C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20220408145205

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: 05/17/2023

NARRATIVE

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LPA interviewed residents and staff on 08/10/2022 at approximately 2:18pm and 01/11/2023 at approximately 2:15pm- 3:50pm. Interviews with three (03) out of six (06) residents confirm they smoke on the front and back patio designated for smoking. Interviews with staff confirm that the facility has two (02) designated patio smoking areas in the facility and it’s up to the residents which patio they choose to smoke on. During the investigation, LPA observed three (03) residents smoking on the back patio and eight (08) residents smoking on the front patio. At the time of the investigation LPA Lacy observed the sister facility that is adjacent to the facility that shares the same exterior lot which is accessible to those independent residents in care. Based on interviews and observations there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazard were noted during this visit.

No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

#4. Facility is operating beyond the terms and conditions of the license.

It is alleged that the facility is running a recycling business. To investigate the above allegation LPA interviewed residents and staff on 08/10/2022 at approximately 2:18pm and 01/11/2023 at approximately 2:15pm- 3:50pm. Interviews with five (05) out of six (06) residents confirm they have not witnessed the facility collecting recyclable items. Interview with resident #1 (R1) confirmed they collect recycled items, and the administrator gave R1 a trash can to keep their recyclable items in. R1 takes their own recyclable items to the recycling center. R1 has not witnessed the facility collect any recyclable items. Interviews with staff affirm they are not running a recycling center and although they have some residents who recycle, the facility is not running a recycling business and does not receive money for recycling. During the investigation LPA did not observe any recycling bins or items in the facility common areas or outside surrounding grounds. Based on interviews and observations there is not enough evidence to prove the alleged violation did or did not occur,

Continued on 9099C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 31-AS-20220408145205

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: 05/17/2023

NARRATIVE

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therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

#5. Staff do not properly maintain the facility

It is alleged that there are stacks of old dirty mattresses on the premises. To investigate the above allegation, LPA interviewed residents and staff on 08/10/2022 at approximately 2:18pm and 01/11/2023 at approximately 2:15pm- 3:50pm. Interviews with six (06) out of (06) residents confirm that the facility is cleaned by staff daily. Staff maintain the facility by sweeping up trash, cleaning bedrooms, changing linens, disposing of trash, and doing laundry. During the investigation, LPA observed staff cleaning bedrooms sweeping, moping, disposing of trash, changing linens and doing laundry. No debris was observed around or on the grounds of the facility. Based on interviews and observations there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and copy of 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: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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