197609076-4-26-2021-31-AS-NGID-C3VMNF-20210611094526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 04/26/2021
Date Signed: 04/26/2021 03:40:31 PM

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
10/14/2020 and conducted by Evaluator Naira Margaryan

COMPLAINT CONTROL NUMBER: 31-AS-20201014160306

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: 48	DATE:	04/26/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kendice Vergara		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff failed to seek medical attention for resident in a timely manner.

Facility staff failed to follow doctor's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Naira Margaryan and Rosaura Valenzuela conducted unannounced subsequent complaint visit to the facility to complete the investigation of the above noted allegations.
LPAs met the Administrator and discussed the purpose of this visit.

---Facility staff failed to seek medical attention for resident in a timely manner.
It was reported that facility resident #1 (R1) missed two (02) medical appointments because the staff lost medical referrals.

During this investigation on 10/21/20, at 10:00am, LPA spoke with the witnesses that were involved with R1’s care. At 10:15am LPA Margaryan conducted an interview with the Administrator and other staff assisting R1 in the facility. At the time of this visit at 2:00pm, LPA Margaryan spoke with the Administrator and obtained additional information pertaining the allegation. Interviews revealed that R1 did not require an assistance with his medical appointments. R1 was managing their own appointments with the Primary Care Physician and with the other specialists.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

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-20201014160306

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: 04/26/2021

NARRATIVE

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(This is an amended copy of the document previously delivered on 04/26/2021. This page was amended to make a correction to the document.)
(Continued from LIC9099) The staff was assisting R1 only to coordinate medical transportation to the appointments. R1 never missed their medical appointments, except those that were made by R1’s Social Worker(SW) without R1’s knowledge and consent.
During initial visit conducted on 10/21/2020 at 11:45am, LPA Margaryan spoke with R1 and they confirmed the information revealed from the facility staff. R1 indicated that they did not consent anyone, including SW to be involved in their medical care and to arrange appointments without their knowledge.
A review of facility records conducted on 04/20/21 at 2:00pm, did not reveal any relevant information to support the allegation.
Based on the interviews and record review there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
--- Facility staff failed to follow doctor's orders.
It was reported that, due to medical condition, R1 cannot leave facility unattended. However, on 10/14/2020, and on 10/15/2020, R1 went to their medical appointments by themselves.
During this investigation on 10/21/20, at 10:00am, LPA spoke with the witnesses that were involved with R1’s care. At 10:15am LPA Margaryan conducted an interview with the Administrator and other staff assisting R1. At the time of this visit at 2:00pm, LPA Margaryan spoke with the Administrator and obtained additional information pertaining the allegation.
Interviews revealed that as per R1’s physician report present in the facility, R1 is an independent resident and able to leave facility unattended. On October 2020 R1’s SW provided a copy of new physician report, identifying that R1 can no longer leave facility unassisted. The report was updated without R1 attending the doctor. As per R1’s request the Administrator assisted R1 to see another doctor who override previous diagnoses preventing R1 from leaving the facility unattended.
On 10/21/2020 at 11:45am, LPA spoke with R1 via face-time and R1 confirmed the information revealed by the Administrator.
A review of facility records conducted on 04/20/21 at 2:00pm, verified the information revealed from the interviews.
Based on interview, and record review, there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
No health and safety hazard is noted during this visit.
Exit interview was conducted and the copy of this report was issues.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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