197609076-10-17-2023-31-AS-NMAN-CX5MKT-20231031094117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:47:07 PM

Unsubstantiated

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
10/12/2023 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20231012185644

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: 61	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Alexis Peralta, Human Resources Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Due to inadequate supervision resident wander away from the facility

Kitchen hood exhaust is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation visit for the above noted allegations. LPA Valenzuela met with Human Resources Director, Alexis Peralta and explained the reason for the visit.

It was reported that due to inadequate supervision resident wander away from the facility. It was alleged that a male resident in their late thirties was wandering away from the facility at night. To investigate this allegation on 10/17/2023 between 3:45pm and 4:00pm, staff interviews were initiated. Interviews revealed that a resident with dementia walked out of the main building and into the patio. Staff found resident #1 (R1) on the facility premises, in the patio area. In the other adjacent facility there are no residents present who are under 65 years of age. In addition LPA conducted a physical plant tour between 12:30pm and 1:00pm and made a note that the facility has alarms and camaras around the facility premises. If a resident exited a facility an alarm would sound off.
Continue on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 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)

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Control Number 31-AS-20231012185644

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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Bases on observation and interviews there is not sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time.

It was alleged that the kitchen hood exhaust is in disrepair. To investigate this allegation between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that the kitchen hood exhaust is not in disrepair. It is turned on from 6;30am until 7:30pm daily. After 7:30pm it is turned off until the following morning. LPA conducted a physical plant tour between 12:30pm and 1:00pm. LPA saw that the kitchen hood exhaust was functional and that did detect a sound. The sound the hood makes is similar to the sound an air conditioner makes. The sound it not too loud, but it is slightly audible.

Based on observation and interviews, there is not sufficient information to verify this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 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)

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