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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:51:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
10/09/2023 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20231009092803
FACILITY NAME:MELROSE VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:68CENSUS: 61DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Alexis Peralta, Human Resources DirectorTIME COMPLETED:
02:46 PM
ALLEGATION(S):
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Staff did not ensure facility was free from bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation visit for the above noted allegation. LPA Valenzuela met with Human Resources Director, Alexis Peralta and explained the reason for the visit.

It was reported that staff did not ensure facility was free from bed bugs. To investigate this allegation on 10/17/2023 between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that facility does have a bed bud investation in room 221A. In order to get rid of the bed bugs the facility replaced all the furniture including the mattresses, and washed all the clothes and linens in the shared room, but the bed bugs continued to be presesnt. Between 12:30pm and 01:00pm, LPA toured the facility and went inside room 221A. LPA did observe bed bugs on the walls and one bug on the bed. Staff told LPA that a fumigating company was scheduled to come today to provide an estimate.

Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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 3
Control Number 31-AS-20231009092803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
VISIT DATE: 10/17/2023
NARRATIVE
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Based on observation and interviews, there is sufficient information to verify this allegation. Therefore, this allegation is SUBSTANTIATED at this time.

Deficiencies will be cited on 9099D.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20231009092803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation-(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintence shall include provision of maintence services and procedures for the safety and well-being of residents, employees, visitors. This requirement was not met as evidenced by:
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Licensee will submit a copy of the pest control invoice to Licensing by 10/31/2023. The invoice shall indicate what treatment was provided to get rid of the bed bug infestation.
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LPA observed bed bugs in one of the resident rooms in the facilty. Staff interviews also confirmed the presence of bed bugs. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3