197609076-5-17-2023-31-AS-NMAN-CT2UPW-20230622154614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:32:23 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
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: 59	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident was left in soiled diapers for an extended amount of time.
Staff not providing adequate food service.
Resident needs are not being met.
Facility has bed bugs.
Residents room not being clean properly.
Facility is short staff.

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 at 10:45am. Upon arrival LPA LaQueena Lacy met staff Alexcis Peralta and explained the purpose of this visit.

#1. Resident was left in soiled diapers for an extended amount of time.

It is alleged that residents are left in soiled diapers. To investigate the above allegation LPA conducted interviews with staff and residents on 01/11/2023 at approximately 2:15pm- 3:50pm. Four out of six residents interviewed are incontinent. Interviews with three (03) out of four (04) incontinent residents confirm they do not wait for long periods of time when needing assistance with a diaper change, and staff comes during the day and night to check if they need to be changed. During the investigation staff affirm that they conduct diaper checks every two hours or more often depending on the need of the resident.
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 5

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: 05/17/2023

NARRATIVE

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Based on interviews and observations, there is not enough corroborating 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, copy of report and appeal rights issued.

#2. Staff not providing adequate food service.

It is alleged that food portions are small or not provided. To investigate the above allegation LPA conducted interviews with staff and residents on 01/11/2023 at 2:15pm- 3:50pm. Interviews with four (04) out of six (06) residents revealed they receive three (03) meals and snacks seven (07) days a week and feels the food portions served are more than enough, and the facility provide second servings when asked. (03) out of (06) residents revealed they ask and receive second servings during mealtime. During the investigation LPA observed food and beverage service delivered to residents on a food cart, and lunch observed to be of good quality and quantity. Residents were observed asking for additional food and drinks during the inspection. Based on interviews and observations, although the allegation may have happened or may be valid, 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, copy of report and appeal rights issued.

#3. Resident needs are not being met.

It is alleged that resident needs are not being met. To investigate the above allegation LPA conducted interviews with staff and residents on 01/11/2023 at 2:15pm- 3:50pm. Interviews with three (3) out of

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 5

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: 05/17/2023

NARRATIVE

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Interviews with three (3) out of six (06) residents confirms their needs are being met by staff and they are available when residents need help. During the investigation, LPA observed staff taking a resident to the shower room, doing laundry, and assisting residents in the activity room. Based on interviews and observations, although the allegation may have happened or may be valid, 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, copy of report and appeal rights issued.

#4. Facility has bed bugs.

It is alleged that the facility has bed bugs. To investigate the above allegation LPA Gary Tan conducted interviews with staff and resident on 06/16/2022 at approximately 9:59am between 10:51am. LPA Lacy conducted additional interviews with staff and residents on 01/11/2023 at 2:15pm- 3:50pm. Interviews with five (05) out of six (06) residents confirm they have not witnessed any bed bugs at the facility and have not been told by another resident that they have seen bed bugs. Interviews with S2 revealed that resident #3 (R3) reported to have bed bugs because they felt something crawling on their body. S2 inspected (R3) bedroom and did not observe any bed bugs, and a deep cleaning of (R3) bedroom was completed. During the investigation, (R3) confirmed they have not seen any bed bugs in their bedroom. LPA Lacy and S2 conducted an inspection of six (06) random bedrooms on the first and second floor, S2 removed bed linens, comforters, pillows and unzipped mattress coverings. LPA inspected mattress seams, bed frames and surrounding area of the bed and did not observe any bed bugs or pests during the inspection. Based on interviews and observations, although the allegation may have happened or may be valid, there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.
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: 3 of 5

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: 05/17/2023

NARRATIVE

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No health and safety hazards are noted during this visit.

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

#5. Residents room not being clean properly.

It is alleged that old food is left in the bathrooms and bedrooms for days. To investigate the above allegation LPA conducted interviews with staff and residents on 01/11/2023 at 2:15pm- 3:50pm. Interviews with five (05) out of six (06) residents revealed that housekeepers duties when cleaning their bedrooms and bathrooms include hanging linens, sweeping, mopping, disposing of all trash, emptying garbage cans and wiping down. During the investigation LPA observed two (02) staff members on the first and second floor cleaning residents’ bedrooms, changing linens, sweeping, mopping and trash in front of resident rooms that was being cleaned. LPA smelled the aroma of cleaning products being used while performing their housekeeping duties. Based on interviews and observations, although the allegation may have happened or may be valid, there is not enough corroborating 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, copy of report and appeal rights issued.

#6. Facility is short staff.

It is alleged that due to being short staff the facility floors, showered/bathe rooms and rooms have old food for days in them and are flithy.

To investigate the above allegation LPA conducted a tour of physical plant on 08/05/2022 at 10:56am. At the time of inspection LPA checked residents’ bedroom, bathrooms, showers, floors and did not observe any obstructions or filthy floors. During the licensing visits LPA observed housekeepers 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 5

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: 05/17/2023

NARRATIVE

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cleaning the rooms. LPA Lacy interviewed staff and residents on 01/11/2023 at 2:15pm- 3:50pm. Interviews with five (05) out of six (06) residents revealed the facility has enough housekeepers to clean the rooms and other areas and they are available to assist residents when needed. They confirm that staff cleans the rooms every day. Interview with staff number #1 (S1) revealed that they have 2 housekeepers working between 8am to 4:30pm and that management is on call if additional staff is needed. During the investigation, LPA reviewed the facility personnel report on 06/01/2022 which identifies two (02) caregivers and (02) housekeeper working in the morning and four (04) caregivers in the afternoon/evening. A subsequent visit was conducted on 08/05/2022 in which LPA obtained a personnel report dated 08/05/2022 that verifies the same information as the previous schedule with addition of one (01) caregiver for the afternoon/evening shifts. At the time of subsequent visit, on 08/05/22, LPA was informed that although no resident had any concerns regarding staffing, facility hired additional staff. Based on interviews and observations, although the allegation may have happened or may be valid, there is not enough corroborating 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, 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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