197609076-7-16-2021-31-AS-MVAO-C54QWE-20210720123149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 06/16/2021
Date Signed: 07/16/2021 11:34:34 AM

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
06/02/2021 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20210602162600

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: 47	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff is providing medical care to residents in care

INVESTIGATION FINDINGS:

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This is an amended report of a visit conducted on 6/16/21. No findings have changed.
Licensing Program Analyst (LPA) Wendell Smith made an unannounced subsequent visit to this facility to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA conducted a previous visit on 6/7/21 to conduct interviews regarding the complaint allegation.
It is alleged that facility staff #1 (S1) is providing medical care to residents by seeing residents once a month and signing their medical assessments. At approximately 10am, LPA reviewed a random sampling of resident's medical assessments and conducted interviews with various residents. At approximately 11:30am, LPA also conducted interviews with facility staff and with S1. A review of medical assessments did not show S1 to have signed any medical assessments. Interviews with residents revealed that S1 is not the physician that they see at the facility and that they have their own choice to see a physician of their choosing. LPA's interview with S1 revealed that they do not see residents in the facility and has not signed any medical assessments of the residents in care. Based on the information obtained through record review and interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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