197609076-12-3-2021-31-AS-NMAN-C9NVN9-20211213153445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:56:21 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
07/23/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210723141045

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: 56	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Kandice Vergara - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is mishandling a resident's personal belongings

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation. LPA met with administrator Kandice Vergara and explained the reason for the visit.

LPA conducted physical plant tour at 12:30 PM, interviewed the administrator at 12:45 PM and requested copy of facility documents relevant to the investigation. It was alleged that Resident #1 (R1)'s collected recyclables are being thrown away by staff. LPA's interview with the administrator revealed that R1 used to store recycled bottles and cans in own room causing clutter and possible infestation in R1's room so the facility had to constantly monitor and clean R1's room to avoid infestation. LPA's interview with R1 today at 1:25 PM revealed that R1 has no problem about personal belongings including collected recyclable as R1 was provided storage bins at the backyard to keep R1's collection. LPA observation at 1:24 PM, confirmed that there are recyclable bins at the backyard of the facility that R1 used. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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 1