197609076-4-5-2023-31-AS-EMIR-CTUNN3-20230718103603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:42:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
03/30/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230330083726

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:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is not providing adequate supervision to residents in care.

INVESTIGATION FINDINGS:

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On 04/05/2023 at 10:10 a.m. Licensing Program Representative (LPA) Evelin Rios conducted an unannounced complaint investigation at the location mentioned above. LPA was greeted by Staff #1 (S1) and granted access. Alexcis Peralta met LPA in the Lobby. LPA explained the reason for the visit. Administrator Kandice was not available for todays visit and designated Alexcis to sign this report.

At 10:20 a.m. a physical plant tour was conducted to ensure no immediate health and safety issues were present. No immediate health and safety issues were noted.

Allegation: Facility is not providing adequate supervision to residents in care.
It is alleged that due to a lack of supervision a resident from the facility left the facility unsupervised and exposed themselves and masturbated in public. To investigate the above allegation LPA conducted interviews with Alexics, and 3 staff from 10:45 a.m. to 11:34 a.m. From 11:35 a.m. to 12:00 p.m. LPA interviewed 6 out 59 residents. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20230330083726

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE VILLAS	FACILITY NUMBER: 197609076
	VISIT DATE: 04/05/2023

NARRATIVE

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(LIC9099-C Continued)
At 12:09 p.m. LPA interviewed Administrator Kandice Vergara by telephone. From 12:20 p.m. to 1:00 p.m. LPA reviewed and obtained documents relevant to this investigation. At 1:00 p.m. LPA interviewed staff #2 (S2) by telephone. At 1:23 p.m LPA interviewed resident #1 (R1).

LPA interviews with staff and residents revealed R1 may have urinated in a corner in the front patio within the gated facility. Furthermore, interviews reveal R1 has a tendency to keep their hands in their pockets. There were no witnesses to corroborate the allegation R1 left the facility and exposed themselves or masturbated in public. LPA's review of R1's records do not indicated inappropriate behavior. Based on interviews and record review, it was concluded that although the allegation may have happened, there is insufficient information and evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No deficiencies cited, exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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