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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609724
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:43:28 PM

Substantiated


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
05/28/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20210528093924
FACILITY NAME:MELROSE CHATEAUFACILITY NUMBER:
197609724
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:819 N POINSETTIA PLTELEPHONE:
(310) 413-8717
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:12CENSUS: 10DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alexis Peralta, ManagerTIME COMPLETED:
04:53 PM
ALLEGATION(S):
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Staff leave residents unattended while in care

Staff do not have planned activities for residents

Residents are unable to leave the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint visit to the facility to deliver the findings for the above noted allegations. LPA met with Alexis Peralta, Manager and explained the purpose of the visit.
During the investigation on 06/03/2021 between 11:04am and 1:00pm, staff and resident interviews were initiated. Interviews revealed that currently the facility has a total of eight (08) residents. There are between one (01) and two (02) caregivers per shift that are also caregivers assigned to Melrose Villas. On 07/26/2021, LPA Valenzuela reviewed staff schedule and facility residents' roster. As per record review, the facility does not have sufficient staff to assist residents. Caregivers and med-techs are shared between the two facilities: Melrose Chateau and Melrose Villas. Caregivers do not have assigned duties to assist specific residents. LPA observed two residents that are non-ambulatory and require the use of a wheelchair to transport. Resident interviews revealed that the facility is short staffed and is not able to meet the residents needs. Indeed, when LPA conducted the initial complaint visit, LPA observed staff coming and going and at times leaving residents
Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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-20210528093924
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 CHATEAU
FACILITY NUMBER: 197609724
VISIT DATE: 03/16/2022
NARRATIVE
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unsupervised and unattended. Based on observation, interviews, and records review, there is sufficient information to support this allegation. Therefore, the allegation is SUBSTANTIATED at this time.

It was reported that staff do not have planned activities for residents. On 06/04/2021 at 4:05pm, LPA spoke to the Activities Director. She indicated that due to COVID-19, all activities were stopped. Activities were resumed with the residents in February of 2021, but only on a one to one basis. Three (03) out of seven (07) residents interviewed on 06/03/2021 between 11:04am and 1:00PM, revealed that no activities are done. Residents complained of being bored. LPA did not observe an activities calendar posted on any facility wall. LPA reviewed the activities calendar for the month of June, but it was for Melrose Villas and not Melrose Chateau.
Based on observation, interviews, and records review there is sufficient information to support this allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under title 22 regulations the following citations are issued and recorded on LIC 9099-D.

No health and safety issue noted.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210528093924
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 CHATEAU
FACILITY NUMBER: 197609724
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2)-Personal Rights-Residents in all residential care facilities for the elderly shall have the following personal rights-(2)-to be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement was not met as evidenced by:
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Licensee will submit LIC 500 indicating staffing schedule to Licensing. Also, Licensee will submit plan in writing explaining how the facility will ensure that care and supervision is provided at all times to residents and how they are protected. In addition, facility will train staff in regards to how to provide care and supervision to
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Based on observation, record review, and interviews facility failed to ensure that residents in care are accorded a safe accommodation as seven (07) out of seven (07) residents were left without supervision while staff came in and out of the facility at various times which poses an immediate health and safety risk to 7 out of 7 residents.
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residents. Admnistrator will submit proof of training to CCL by 3/23/2022.
Type B
03/23/2022
Section Cited
CCR
87219(a)(1-6)
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87219(a)(1-6) Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization...(2) Daily living skills/activities...(3) Leisure time activities...(4) Physical activities..(5) Education...(6) Provision for free time...
This requirement was not met as evidenced by:
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The Licensee shall ensure that all residents are encouraged to participate in individual and group activities. A copy of a monthly activity schedule for the month of March 2022 shall be submitted to CCL by POC date.
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Licensee did not provide planned activities to residents in care. LPA interviewed three (03) out of seven (07) residents who revealed that they are bored due to the lack of activities. LPA did not observe any resident engaged in any activity or see an activity calendar posted in the facility which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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
05/28/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20210528093924

FACILITY NAME:MELROSE CHATEAUFACILITY NUMBER:
197609724
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:819 N POINSETTIA PLTELEPHONE:
(310) 413-8717
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:12CENSUS: 10DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alexis Peralta, ManagerTIME COMPLETED:
04:53 PM
ALLEGATION(S):
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Residents are unable to leave the facility
INVESTIGATION FINDINGS:
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This is an amended copy of the licensing report previously issued on 3/16/2022. The report was amended because it mistakenly said that further investigation was needed. Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint visit to the facility. LPA met with Alexis Peralta and explained the purpose of the visit.
It was alleged that residents are unable to leave the facility. To investigate this allegation, at 2:45pm, LPA Valenzuela inspected the facility and checked the facility's main entrance door. Facility has delayed egress doors approved by the fire department. LPA was able to open the door from the inside, but not from the outside since it is locked. LPA never heard the alarm go off, when the door was opened. LPA was told that alarm is not working, but that it is about to be repaired.
Three residents were interviewed on 6/03/21 at 11:40am and said that they are able to exit the facility, but have a hard time getting back inside since the door is locked from the outside.
Based on observation, interviews, and record review there is not sufficient information to conclude that residents are not able to leave the facility. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022
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