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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 04/20/2021
Date Signed: 07/10/2021 07:18:56 PM



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
11/13/2020 and conducted by Evaluator Naira Margaryan
COMPLAINT CONTROL NUMBER: 31-AS-20201113103910
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: 50DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kendice VergaraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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---- Door to resident's room is difficult for resident to open.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Naira Margaryan made subsequent complaint visit to the facility to continue investigation of the above noted allegations. The purpose of visit was discussed with the Administrator Kandice Vergara.

Concerns were addressed that the resident #1 (R1) uses a walker and finds it difficult to get in and out of their room because the door has a spring-loaded hinge and R1 does not always have the physical strength to open the door.

To investigate the allegation, on 11/20/2020 at 8:30am, LPA spoke with the facility staff and was informed that the doors in residents’ bedrooms are fire doors and have a self-egress system. The residents may need to apply a little force to open the doors.
On 11/20/20 at 9:45am, LPA Margaryan inspected the facility via face-time and asked the staff to open and close R1’s bedroom door. While opening the door, the staff had to apply a force on the doorknob.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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 7
Control Number 31-AS-20201113103910
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: 04/20/2021
NARRATIVE
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At the time of this visit at 11:30am, LPA inspected the facility and checked the doors of seven (07) bedrooms located on the first floor. All bedroom doors had a self-closing hinge. LPA Margaryan had to apply a force to open (05) out of seven (07) doors.
Based on the interviews, inspection and observation there is a sufficient information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under Title 22, Division 6, Chapter 8, following citations were issued and recorded on LIC9099D.
Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20201113103910
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2021
Section Cited
CCR
87468.1
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87468.1. Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by.
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At the time of this visit LPA observed the maintenance person adjusting the doors.
Upon completion of the project and by POC due date, the Administrator will inform the LPA in writing about the adjustment of the bedroom doors, to be opened without applying a force.
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Based on interviews and record review, the Licensee did not ensure that residents are accorded with a safe and comfortable accommodation. The residents #1 was having hard time to open the bedroom door. This poses a potential personal rights violation 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/13/2020 and conducted by Evaluator Naira Margaryan
COMPLAINT CONTROL NUMBER: 31-AS-20201113103910

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: DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not following resident's modified diet.
Facility is not safeguarding resident's belongings.
Food served at the facility is not of the quality or quantity to meet the needs of the residents.
Facility has rodent infestation.
Facility is not kept clean.
INVESTIGATION FINDINGS:
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This page was amended to add previously missed information from the report delivered on 04/20/2021.
Licensing Program Analyst (LPA) Naira Margaryan made subsequent complaint visit to the facility to continue investigation of the above noted allegations. The purpose of visit was discussed with the Administrator Kandice Vergara.
--- Facility is not following resident's modified diet.
It was reported that facility resident #1 (R1) is struggling to get the food he can eat. R1 has a health condition requiring special food. The list of the food items was provided to the management, but they did not follow.

To investigate the allegation, on 11/20/2020 between 8:30am and 10:30am and at the time of this visit at 9:00am, LPA Margaryan spoke with the Administrator, assistant administrator, med tech, cook and other facility staff. Interviews revealed that due to health condition, R1 is requiring to eat the food that was recommended by the doctor. Every week R1 was providing the list of the food items a resident could use and the staff was doing grocery shopping for R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20201113103910
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: 04/20/2021
NARRATIVE
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The kitchen staff was preparing the meal for R1 by using the food that was purchased for R1. As per R1's request, the cook was using a soybean oil to cook R1's meal.
On 11/20/2020 between 9:45am and 10:45am and at the time of this visit at 12:00pm, LPA spoke with four (04) out of eighteen (18) residents that were on special diet. No resident addressed any concerns about the food, and they verified that kitchen staff is making special diet food, as prescribed by their doctors.
On 11/20/2020 at 9:00am, LPA inspected the kitchen and observed the list of the residents requiring special diet, hanging on the wall.
A review of the documents conducted on 04/19/2021 at 11:00am, verified the information revealed from interviews.
Based on the interviews, inspection and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Food served at the facility is not of the quality or quantity to meet the needs of the residents.

Concerns were addressed that sometimes residents dump their meals in the trash, because the food tastes so bad.
During investigation on 11/20/2020 at between 8:30am and 10:30am, LPA Margaryan spoke with facility staff including the dietary personnel. Information received revealed that the facility menu is followed, and residents are satisfied with the quality and quantity of the food served during meal time.
On 11/20/2020 at 9:00am and at the time of this visit, at 12:00pm LPA Margaryan inspected the kitchen and observed the food cooked and served to the residents. The breakfast served to the residents consists of eggs, pancakes and bacon. The residents also offered cold and hot cereal or oatmeal as well as milk, juice or coffee. LPA observed that the cook was making a Fish, Sweet mashed potato and boiled vegetables for lunch. The residents received sufficient portions of the food.
On 11/20/2020 between 9:45am and 10:45am, LPA Margaryan spoke with eight (08), out of fifty-four (54) residents and no one addressed any concerns about quality and quantity of facility food.
On 04/19/2021 at 12:00pm, facility food menu was reviewed and meet food service requirements.

The information revealed during this investigation, does not support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20201113103910
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: 04/20/2021
NARRATIVE
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--- Facility is not safeguarding resident's belongings.
It was reported that since Resident #1 (R1) moved in, they had no key to lock their bedroom. R1 got the key a week ago. During the time when R1 was unable to lock the room, other residents would go into R1's room, and take their belongings; mostly the food that R1 kept stored.
During investigation, on 11/20/2020 at 8:30am, LPA Margaryan spoke with the Administrator and other facility staff. Interviews revealed that at the time of admission, R1 had a key for the bedroom. Within one year, R1 lost the bedroom key twice and the staff ordered duplicate key both times. While waiting for the duplicate key, R1 was locking the door when leaving the room and asking the staff to open the door to go back to the room. The staff indicated that R1 was residing in the facility for about two years and R1 never complained of missing or lost items and food.
On 11/20/20 at 9:45am, LPA Margaryan spoke with eight (08) out of fifty-four (54) residents and no resident complain about stolen or missing personal items.
Based on interviews and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility has rodent infestation.
It was reported that because of spills on the floor and garbage cans not being emptied regularly, there is a rodent infestation in the facility.
To investigate the allegation, on 12/20/2020 at 8:30am, LPA Margaryan spoke with the Administrator and other staff, including housekeepers. Staff denied seeing rodents in the residents’ rooms or in the common areas. The Administrator stated that they have ongoing contract with the pest control company and facility is being fumigated for the insects and rodents every month.
On 11/20/2020 at 9:45am, LPA Margaryan inspected residents’ bedrooms and spoke with the eight (08) out of fifty-four (54) residents present in their rooms. At the time of this visit at 11:30am, LPA inspected additional bedrooms, kitchen, common areas and found no insects or rodents. At 1:00pm, LPA spoke with four (04) additional residents. Residents interviewed during this investigation denied seeing insects or rodents in the facility.

A review of the documents regarding pest control contract and visits, conducted on 04/19/2020 at 12:30pm, verified the information revealed from the staff.
Based on interviews, inspection and record review there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20201113103910
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: 04/20/2021
NARRATIVE
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--- Facility is not kept clean.
It was reported that residents are eating in their rooms and spill on the floor and garbage cans not being emptied regularly.

During this investigation on 11/20/2020 at 8:30am, LPA Margaryan spoke with facility staff including housekeepers. Staff indicated that residents’ rooms are being cleaned daily, especially after meal time. The trash cans are being emptied at list once a day.
On 11/20/2020 at 9:45am and at the time of this visit at 11:30am, LPA Margaryan inspected residents’ rooms and observed housekeepers cleaning the rooms. At the time of this visit, the residents’ rooms, common areas, hallways appeared to be clean and the trash cans were empty. During inspection, LPA Margaryan spoke with eight (08) out of fifty-four (54) residents present in the room and they stated that every day housekeepers are coming to clean the rooms and taking the trash out.
The information revealed during this investigation does not verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazard was noted during this investigation.
Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7