197609076-4-18-2022-31-AS-NMAN-CE5VZ8-20220505165219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:14:30 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
10/19/2021 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20211019153111

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: 62	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident involuntarily moved to another facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 04/18/2022 at 11:10am for the purpose of delivering investigative findings. LPA Lacy met with Alexcis Peralta and explained the purpose of the visit.
LPA Lacy conducted a physical plant tour at 11:21am, no immediate health and safety concerns observed.
It is alleged that resident #1 (R1) was involuntarily moved to another facility. To investigate the above allegation, LPA conducted an initial complaint visit on 10/27/2021. LPA requested documents relevant to the investigation at 10:39am and began interviews with the Administrator and staff at approximately 10:41am. Interviews revealed that R1 was transferred from the facility due to exhibiting uncontrollable behaviors. Administrator indicated that R1 was placed in the facility by a placement agency operating under the Department of Health Services (DHS). Prior to relocation, a relocation request was submitted and approved by the placement agencies. During the investigation on 03/18/2021, LPA interviewed R1 and various witnesses by phone approximately between 2:18pm – 3:43pm.
Continue on LIC9099C.

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: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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-20211019153111

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: 04/18/2022

NARRATIVE

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Interviews verified that R1 was placed at the facility by DHS and the facility must have an approval from DHS before relocating their residents, by submitting a relocation request. To assist with R1’s housing and other needs and services DHS correlate with two placement agencies, by assigning a housing coordinator and case manager. Two (2) out of four (4) witnesses interviewed, stated “R1’s case manager and housing coordinator left the job around the time the relocation occurred”. Six (6) out of (6) witnesses interviewed were not R1’s case manager prior to or at the time of the relocation. During the investigation, upon record review, LPA observed that a relocation request was submitted to DHS on 10/08/2021, no objections were received for the relocation and the request was approved on 10/27/2021 at 11:30am via e-mail confirmation received by the administrator.
Based on interviews and record review, it was concluded that although the allegation may have happened, there is an 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 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: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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