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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:17:16 PM


Document Has Been Signed on 06/20/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:68CENSUS: 54DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
03:15 PM
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On 06/20/24, 9:40 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced Annual visit at this facility. LPA met with Facility Administrator, Alexcis Peralta, and reason for the visit was disclosed.

Facility is licensed as a two-story residence, with 34 shared resident bedrooms, each with bathroom, and three (3) bathrooms for public use located in hallways paths. Fire clearance approved for sixty-eight (68) non-ambulatory residents, of which, twenty (20) may be bedridden. Hospice waiver is for twenty (20) residents.
At the time of this inspection, the Facility occupied thirty-one (31) ambulatory residents, and seventeen (17) non-ambulatory residents, one (1) of which is bedridden. Currently, eight (8) of the Facility's residents are receiving hospice care services.

At 11:40 AM, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary access, with three (3) emergency exits on the first floor, and two (2) emergency exits on the second floor. Emergency exit routes are clear of obstructions. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 72 °F., within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 6/19/2024.

[LIC 809C-Continued]
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2024
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Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date.

Exit interview conducted/Copy of report given to Administrator, Alexcis Peralta.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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