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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 07/21/2025
Date Signed: 03/10/2026 10:39:19 AM

Substantiated


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
04/09/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250409171120
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:
07/21/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Saul Aranda, Maintenance DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not ensure that resident received medical treatment.
Staff do not ensure that client's mental health needs are met.
Staff did not keep the facility free of cockroaches.

INVESTIGATION FINDINGS:
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This is an Amendment to the original report issued 07/21/2025. Additional information was added to clarify the investigation. At 10:15 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit and met with the front desk receptionist Cleef Dizon, and later with the Maintenance Director (MD) Saul Aranda. LPA explained the reason for the visit.

An initial complaint visit was conducted on 04/14/2025. At 10:20 AM, LPA requested client and staff roster. At 10:25 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:30 AM, LPA conducted a physical plant tour. Between 10:40 AM – 1:45 PM, LPA conducted an interview with the Administrator, two (2) staff, a MedTech and eight (8) residents. During today’s visit, LPA conducted additional interviews with MD, MedTech #2, R1's Primary Physician, Former Administrator Alexcis Peralta, and an Associate Director (AS) of Department of Health Services.
Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
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 4
Control Number 31-AS-20250409171120
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: 07/21/2025
NARRATIVE
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Allegation: Staff did not ensure that resident received medical treatment.
Regarding the allegation “Staff did not ensure that resident received medical treatment,” it was alleged that facility staff failed to secure medical care for Resident #1 (R1) after R1 sustained a burn injury to his/her feet. To investigate the allegation, during the initial complaint visit on 04/14/2025, LPA conducted interviews with the Administrator, MedTech #2, two (2) staff members, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, MD, Primary Physician, and MedTech #1. Interview with the Administrator revealed that on 03/07/2025, R1 spilled boiling water on his/her feet and staff offered medical assistance and hospital transport; however, R1 refused. LPA reviewed the Special Incident Report (SIR) and did not observe documentation of any 9-1-1 call or outside medical transport. Interviews with MedTech #1 confirmed the burn incident and that no 9-1-1 call was made. MedTech #1 stated R1 refused medical treatment and hospital transport. The MD confirmed that no formal outside medical assessment was arranged and documentation of refusal of care was incomplete. The Primary Physician informed LPA that he advised staff to transport R1 to the hospital for evaluation; however, the facility did not follow this recommendation. Interview with R1 at 12:15 PM confirmed the incident occurred; however, R1 stated he/she declined hospital transport. R1 further indicated receiving informal treatment with cream and home remedies but no outside medical evaluation. During the interview with R1, LPA observed the burnt present on R1’s feet and not being healed or covered. Based on interviews and record review, the facility failed to ensure appropriate medical follow-up after the burn injury and did not document refusal of care per policy. The facility also failed to follow the physician’s recommendation for outside medical evaluation. Therefore, the allegation is Substantiated.

Allegation: Staff do not ensure that client's mental health needs are met.

Regarding the allegation “Staff do not ensure that client’s mental health needs are met,” it was alleged that R1’s psychiatric and mental health needs were not addressed. To investigate the allegation, during the initial visit on 04/14/2025, LPA conducted record review and interviews with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, the Associate Director of the Department of Health Services, and MedTech #1. Interview with the Administrator revealed that psychiatric appointments are scheduled but that R1 frequently refuses to attend. However, documentation of scheduled appointments and refusal forms was not provided. Record review did not reveal evidence of appointment scheduling or care plan updates addressing mental health services. Interview with the Former Administrator confirmed awareness of psychiatric services but stated that responsibility for scheduling appointments had been transferred to the Department of Health Services social worker.

Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20250409171120
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: 07/21/2025
NARRATIVE
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The Associate Director of the Department of Health Services clarified that the facility remains responsible for arranging psychiatric services and transportation, though the department assists with coordination. No documentation of appointment scheduling was provided. Interviews with MedTech #1 indicated that R1 often refuses services but no formal documentation of refusals were made such as reappraisal and or incident reports. Moreover, LPA reviewed all incident reports on a system and did not observe an incident report regarding psychiatric appointment refusals. Based on interviews and documentation review, the facility failed to demonstrate efforts to arrange or document psychiatric services for R1. The lack of evidence supporting mental health follow-up supports the allegation. Therefore, the allegation is Substantiated.

Allegation: Staff did not keep the facility free of cockroaches



Regarding the allegation that staff did not keep the facility free of cockroaches, it was alleged that the facility had an infestation of cockroaches and bedbugs. To investigate the allegation, during the initial visit on 04/14/2025 at approximately 10:30 AM, LPA toured the facility and observed the general condition of the physical plant. Interviews were conducted with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents. During a subsequent visit on 07/21/2025, additional interviews were conducted with the former Administrator, MD, and MedTech #1.

During interviews, the Administrator, staff, MedTechs, and MD confirmed that the facility had experienced issues with cockroaches and bedbugs. MD reported that the facility is contracted with a pest control vendor, Ecolab, which is currently providing facility-wide pest control treatments to address the pest issues. Additionally, one (1) out of eight (8) residents interviewed reported witnessing bedbugs in their bedroom and cockroaches in the facility’s main elevator.

Although LPA did not observe cockroaches or bedbugs during the facility tours, based on staff confirmations and the resident statement, there is sufficient evidence that pests were present in the facility. Therefore, the allegation is Substantiated.



Deficiencies issued and appeal rights explained and given.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250409171120
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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On 06/20/2025, LPA Raymond Comer issued a deficiency for complaint control # 31-AS-20250613093622 in which the Administrator has agreed to work with facility's pest control vendor to create a proposal for the enhanced treatment and eradication of pests in the facility.
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Based on interviews, staff failed to ensure that the facility is free from insects and pests, this poses a potential health and safety and personal rights risk to persons in care.
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During today's visit, LPA received copy of the proposal and cleared the deficiency during today's visit.
Type B
07/28/2025
Section Cited
CCR
87468.1(a)(2)
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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 all of the following personal rights:(2) To be accorded safe, healthful..... .
This requirement is not met as evidenced by:
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The Licensee will develop a plan to ensure residents are receiving their medical and mental health treatments timely and correctly. The plan must be submitted to LPA by POC due day.
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Based on interviews and record review medical treatment and Psychiatrist appointments were not given to R1 timely. This poses a potential health and safety and personal rights risk to persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4