197609076-5-17-2023-31-AS-NMAN-CT2VYA-20230622165048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:58:53 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
01/25/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220125084840

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:	11:55 AM
MET WITH:	Alecis Peralta		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff sexually assaulted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 05/17/2023 at 10:45am to deliver investigative findings. LPA Lacy met with staff Alexcis Peralta and explained the purpose of the visit.

It is alleged that resident #1 (R1) was sexually abused by staff #1 (S1). S1 threw R1 to the floor and got on top of them. To investigate the above allegation LPA requested documents relevant to the investigation on 08/26/2022. Interviews conducted with residents on 08/26/2022 between 3:00pm- 3:45pm revealed that five (05) out of (05) residents have not witnessed or been told by another resident that R1 have been sexually abused by staff. Residents stated that they have not witnessed staff hit any residents in care and staff treat them well and assist them when they need help. During the investigation, interviews with staff #2 (S2) on 01/26/2022 at 10:00am revealed they witnessed the incident between R1 and S1 and observed R1 grab S1 arm and scratched it.
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)

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Control Number 31-AS-20220125084840

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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S1 then pulled their arm away from R1, as a result S1 arm hit R1 chest, "which was not intentional”. Interviews with the administrator on 08/26/2022 at 2:57pm revealed that they conducted an internal investigation of the alleged sexual abuse and R1’s allegation towards S1 was determined to be untrue. S1 has not had any prior complaints made by R1 or any other resident in care. Based on LPAs interviews, and observation, 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 immediate health and safety hazard were noted during this visit.

No deficiencies cited. Exit interview conducted and a copy of 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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