197609076-10-10-2021-31-AS-NMAN-C9NVNA-20211213153445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 10/09/2021
Date Signed: 10/10/2021 01:55:02 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:	10/09/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Desiree Richie - Activity Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff do not meet a resident's dietary requirements
Resident is being harassed by staff while in care
Staff threatened a resident with eviction
Staff do not have planned activities for the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to investigate the above allegations. LPA met with staff Desiree Richie and explained the reason for the visit.

LPA conducted physical plant tour at 9:30 AM, requested facility documents relevant to the investigation at 10:00 AM and interviewed residents and staff between 10:30 AM to 1:00 PM. Regarding the allegation that Staff do not meet a resident's dietary requirements, it was alleged that sometimes staff gives hard food that Resident #1 (R1) cannot chew. LPA record review revealed that there was no doctor's order for R1's diet but has a recommendation for a temporary soft diet due to R1's denture situation. LPA's observation during 07/27/21 at 9:18 AM and today's visit at 12:05 PM, revealed that R1's food are prepared based on the recommendation and agreed to by R1.

(continued on LIC 9099)

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: 10/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2021

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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Control Number 31-AS-20210723141045

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: 10/09/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Resident is being harassed by staff while in care, it was alleged that a number of staff is harassing R1. LPA's interview with R1 on 07/27/21 at 11:05 AM revealed that R1 was not harassed by any staff and were respectful to R1.

Regarding the allegation that Staff threatened a resident with eviction, it was alleged that R1 was told that R1 needed to move to Pasadena. LPA's interview with R1 on 07/27/21 at 11:05 AM revealed that R1 was offered to move to their sister facility in Pasadena and R1 admitted that it was optional and not mandatory and stayed at this facility. LPA's interview with staff today at 11:35 AM, also revealed that all alert residents at this facility are offered to move to their sister facility in Pasadena but that was optional and only if the resident wants to.

Regarding the allegation that Staff do not have planned activities for the residents, it was alleged that the calendar on the wall is only there for decorations because there are no events happening. LPA's record review revealed that the facility has the activity calendar and abide by it. LPA's interview with six (6) residents or more than 10% of the current census, revealed that the facility has activities but only three (3) out six (6) residents participates regularly.

Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2021

LIC9099 (FAS) - (06/04)

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