197609076-10-10-2021-31-AS-NMAN-C9P2CY-20211213161732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 10/09/2021
Date Signed: 10/10/2021 02:53:50 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
07/27/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210727105831

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:	01:45 PM
MET WITH:	Desiree Richie - Activity Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Residents are not being provided their medications in a timely manner
Staff not available to help 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 1:45 AM to 3:00 PM. Regarding the allegation that Residents are not being provided their medications in a timely manner, it was alleged that Resident #1 (R1) has not been provided up to four (4) hours without his medication. LPA's interview with R1 on 07/27/21 at 1:45 PM, revealed that R1 took medication on time almost all the time. LPA's interview with staff today at 1:48 PM however, revealed that R1 always leave in the morning before the morning medication is given and R1 would like own medication to be left in own room, which is against the medication policy. LPA record review today at 1:50 PM, revealed that R1 agreed to wait for the morning medication to be given before leaving the facility. (continued on LIC 9099-C)

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-20210727105831

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 Staff not available to help residents, it was alleged that R1 hasn’t had clothes several times due to laundry was not completed. LPA's interview with R1 on 07/27/21 at 1:45 PM, revealed that the staff do R1's laundry regularly every Saturday. LPA observation on 07/27/21 at 2:00 PM and today at 2:01 PM, revealed that R1 mixed own clothes at one place both clean and dirty.

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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