197609076-5-17-2023-31-AS-NMAN-CSXTFA-20230619144113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:45:37 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
09/08/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220908141544

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:	12:52 PM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident not accorded dignity in relationships with residents and other persons.
Call button not accessible for resident use.

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.

It is alleged that resident #1 (R1) is being intimidated and yelled at by another resident. To investigate the above allegation LPA Abeye Duguma interviewed staff and residents on 09/09/2022. LPA Lacy conducted additional interviews with staff and residents at approximately 2:15pm- 3:50pm on 01/11/2023. Interviews with five (05) out of (07) seven residents confirmed they have not been prevented from having relationships/friendships with other residents and have not been restricted from communicating with other residents. They have not witnessed any residents being abused, yelled at, or harassed at the facility by another resident, and have not been told by another resident that they are being abused or harassed. During the investigation, interviews with staff determined they have not been told by any residents that they are being abused or
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 2

Control Number 31-AS-20220908141544

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. Call button not accessible for resident use.

It is alleged that resident #1 (R1) cannot reach the call button for assistance. To investigate the above allegation LPA Abeye Duguma interviewed staff and residents on 09/09/2022. LPA Lacy conducted additional interviews with staff and residents at approximately 2:15pm- 3:50pm on 01/11/2023. Interviews with five (05) out of (07) seven residents revealed they have not had to utilize the call button in their bedroom, and they are accessible if they need to use it. During the investigation LPA and S1 inspected ten (10) random bedrooms. Seven (07) out of (10) bedrooms observed had pullcords in measurement of 3ft to 4ft 2in for a single occupancy bedroom, and two (02) pullcords for shared bedrooms in measurement of 3ft 10in to 6ft accessible to clients. Upon record review of R1s physician report, R1 has physical limitations and motor impairment/paralysis at times secondary to Parkinsons disease. 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.