197609076-7-27-2021-31-AS-NMAN-C9NVNB-20211213153445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 07/27/2021
Date Signed: 07/27/2021 02:41:35 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: 52	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Kandice Vergara - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's room is in disrepair

Staff do not provide appropriate laundry services

Staff do not provide assistance with hygiene products for residents

INVESTIGATION FINDINGS:

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

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

LPA conducted physical plant tour at 9:18 AM. Requested pertinent facility documents relevant to the investigation at 10:00 AM and conducted interview with staff and resident between 10:05 AM to 1:00 PM. Regarding the allegation that the facility is in disrepair, LPA observation during physical plant tour at around 9:25 AM revealed that everything in Resident #1 (R1)'s room is in good repair. LPA also checked the sink and toilet and was observed to be fully functional and in good repair. LPA interview with R1 at 10:05 AM confirmed that all the furniture is in good repair and the sink is operational. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

(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: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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 3

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: 07/27/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099)

Regarding the allegation that staff do not provide appropriate laundry services, LPA interview with R1 revealed that R1 was aware and confirmed that own personal clothes are being washed every Saturday. LPA record review also revealed that R1's laundry schedule is every Saturday and caregivers' logged showed that R1's clothes are washed for the last eight (8) weeks. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Regarding the allegation that staff do not provide assistance with hygiene products for residents, LPA interview with R1 revealed that R1 is being provided with hygiene products, (e.g., shampoo, soap) whenever R1 asked for it. LPA observation also revealed that R1 had soap and shampoo in R1's room during visit. Moreover, LPA observation also revealed that the facility has sufficient stock of personal hygiene products in their storage for distribution. Based on the information gathered during this visit, the allegation is 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: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3