197609076-5-7-2021-31-AS-NMAN-C8MR42-20211110114048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 05/06/2021
Date Signed: 05/07/2021 10:39:18 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
02/08/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210208134358

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: 48	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	, Alexis Peralta, Assistant Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff did not safeguard resident's personal property

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Naira Margaryan conducted a subsequent complaint investigation for the above noted allegation. LPAs met with Alexis Peralta Assitant Administrator. The purpose of the visit was discussed.

It was reported that facility staff did not safeguard resident #1 (R1's) personal property. On 12/24/21, R1 transferred out of the facillity and subsequently realized that some personal items were missing. The missing items include but are not limited to: over 100 DVDs, an Apple charger, and Apple earbuds. To investigate the allegation on 02/16/21 at 2:30pm and on 04/26/21 at 4:00pm, LPA Valenzuela spoke with facility staff. Staff indicated that R1 resided at the facility for about two (02) weeks. Staff inventoried R1's personal property at the time of entrance. When R1 moved out of the facility, the staff put their belongings in bags and left them outside of the facility to be picked up by a family member. Staff admitted that they did not review the inventory record
of R1's personal belongings with R1 or their family member to ensure that all items belonging to R1 were packed and no items were left behind.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

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 4

Control Number 31-AS-20210208134358

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: 05/06/2021

NARRATIVE

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A review of R1's inventory record conducted on 04/26/21 at 4:00pm, confirmed that some of the items: over 100 DVDs, an Apple charger, and Apple ear buds missing from R1's personal belongings were recorded on the inventory sheet.

The investigation revealed that upon R1's discharge and prior to releasing R1's belongings to their family member, staff did not review R1's inventory record to ensure that R1's belongings were not missing or were left behind. In addition, staff did not take appropriate measures to ensure that R1's personal belongings entrusted to the facility were safely transferred.

Based on interviews and record review, there is sufficient information to support the allegation. Therefore, at this time the allegation is SUBSTANTIATED.

Per title 22 regulations, a citation is issued and recorded on LIC 9099D.

Exit interview conducted. A copy of the report was given and signature obtained.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20210208134358

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: 05/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2021 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables-(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property & valuables which have been entrusted to the licensee or facility staff.	1 2 3 4 5 6 7	Administrator will make sure that all residents cash resources, personal property & valuables are safeguarded by documenting on the inventory list what items the residents have when they entered the facility and upon departure from the facility.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff left R1's personal belongings out in the street unattended and did not document what items were placed outside of the facility. This poses a potential hazard to the health and safety of the residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
02/08/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210208134358

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: 48	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	,Alexis Peralta, Assistant Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff did not update resident's records.

INVESTIGATION FINDINGS:

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3
4
5
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7
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9
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13

Licensing Program Analysts (LPAs) Rosaura Valenzuela and Naira Margaryan conducted a subsequent complaint investigation for the above noted allegation. LPAs met with Alexis Peralta, Assistant Administrator . The purpose of the visit was discussed.

It was reported that facility staff did not update the inventory list when the resident # 1 (R1) left the facility. During this investigation, on 04/26/21 at 4:00pm, LPA spoke to staff. Staff indicated that R1 only stayed at the facility for two (02) weeks and then moved out. R1 did not ask facility to re-itemize belongings.

Based on interviews and record review, there is no sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of the report was given to administrator and a signature was obtained.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

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 4