<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 06/21/2024
Date Signed: 06/23/2024 11:18:12 AM


Document Has Been Signed on 06/23/2024 11:18 AM - 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:
06/21/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
03:15 PM
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
Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 06/20/2024. LPA met with Administrator, Alexcis Peralta, and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Fire Safety: Fire Detection/Protection system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system back up and tests are completed and documented on a biannual basis. Fire Alarm System was tested and working properly. Fire drill last conducted 5/30/2024. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/11/2024. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. However, LPA observed there are no evacuation chairs in the stairwells of the facility

Kitchen: At 11:30 AM LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents.

Medications: Located on the second floor, medication room is secured. locked, and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. First Aid kits are complete.

Laundry: Room is located on sub-floor level. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

[Continued on LIC 809C]

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 06/21/2024
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
Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean and furnishings to be in good condition. No obstructions, nor tripping hazards observed.

Bedrooms: At 12:15 PM, LPA observed random bedrooms as clean with sufficient lighting, bed linens, at least one chair, nightstand, closet space, and dresser. Signaling system was tested and is working properly. Staff responded to activated signal within three minutes.

Bathrooms: LPA observed bathrooms to be clean and sanitary, with required safety fixtures. (grab bars, anti-slip floor stripping) Hot water temperature measured at 118.°F., within the required range. While inspecting bedrooms #204 #210, #103, and #107, LPA observed multiple deficiencies, such as unstocked paper towel supplies, cracked bathroom glass mirrors, burned out bathroom light bulbs, and loose screws on door handles.

Outdoor: Courtyard observed to have a shaded patio area, with a table, and sufficient seating for residents. Outdoor furniture observed to be in fair condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All outdoor sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility.



Resident records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: LPA observed records stored in a locked and secured records room on the first floor, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current.

Per the CCR, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited: (Refer to the following pages LIC 809-D for list of deficiencies)

Exit Interview conducted, report given, and Appeal Rights discussed with Administrator, Alexcis Peralta.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 06/23/2024 11:18 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(f)(1)

(f) A facility shall have the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA osbervation, the licensee did not comply with the section cited above by not having the required evacuation chair in their stairwell, which posses a potential health and safety, or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
1
2
3
4
The licensee agrees to purchase an evacuation chair for placement at each stairwell at the facility, and will submit proof of purchase to CCL on or before the POC date.
Type B
Section Cited
CCR
87303(a)
87303(a)- Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation on inspected bedrooms #204, #103, #210, #203, the licensee did not comply with the section cited above. LPA observed burned out light blubs, cracked mirrors, and loose door handle screws in resident bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
1
2
3
4
The licensee agrees to submit proof of the completed repairs by the POC date.
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: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3