197609076-11-15-2023-31-AS-NMAN-CXRQLP-20231120111616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:42:11 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
05/10/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210510121903

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:	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:			TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are restraining clients.
Facility does not have adequate supervision.
Facility failed to provide timely medical attention.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with lead staff, Alexcis Peralta, and explained the reason for the visit.

--- Facility staff are restraining clients.

It was alleged that staff restrain residents using a four-pin restraint mechanism. To investigate the allegation on 11/15/2023, LPA Duguma made observations during the physical plant tour, interviewed three (03) staff from 11:00 AM - 12:00 PM and six (06) residents from 1:00 PM – 2:30 PM. During the unannounced visit, LPA did not witness any residents in restraints.

(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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-20210510121903

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: 11/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During interviews with staff, all staff stated they have never restrained a resident or witnessed any staff restrain a resident. During interviews with residents, all residents stated that they have never been restrained or witnessed others being restrained.
Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility does not have adequate supervision.

It was alleged that residents that require supervision wander the neighborhood. To investigate the allegation on 05/20/2021, LPA Alex Pitz interviewed staff. On 11/15/2023, LPA Duguma made observations during the physical plant tour and interviewed three (03) staff from 12:00 PM - 1:00 PM. During the physical plant tour, LPA observed delayed egress doors at every exit in working order. During interviews with staff, all staff stated that there are some residents that are very independent and can leave the facility and return without any need for supervision. Staff added that the facility is equipped with delayed egress doors to notify staff when residents are attempting to leave the building and they do not recall any wandering incidents around the time in question.
Based on interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility failed to provide timely medical attention.

It was alleged that a resident had fallen out of their wheelchair outdoors and was left without assistance for an extended time. To investigate the allegation on 11/15/2023, LPA interviewed three (03) staff from 11:00 AM - 12:00 PM and six (06) residents from 1:00 PM – 2:30 PM. During interviews with staff, all staff stated they have never experienced a situation where a resident fell out of their wheelchair and was unassisted for an extended time. During interviews with residents, all residents stated they have never witnessed anyone left on the floor without assistance after falling out of their wheelchair and have never experienced that for themselves.
Based on interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.
Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2