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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609724
Report Date: 08/22/2022
Date Signed: 08/22/2022 05:02:50 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
08/15/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220815152802
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: 63DATE:
08/22/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Alexcis PeraltaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident received improper eviction notice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Alexcis Peralta and explained the reason for the visit. The Administrator designated Alexcis Peralta as the responsible staff member to sign and accept this report.

It was alleged that Resident #1 (R1) was given an improper 30-day eviction notice. To investigate this allegation, on 08/22/2022, LPA conducted a physical plant tour at 11:30am, requested documents at 12:45pm and interviewed two (02) staff and seven (07) out of sixty-three (63) residents from 1:45pm - 3:45pm. Record reviews and interviews revealed that the facility issued an eviction notice based on the isolated incident of the violation of house rules. However, no appropriate actions were taken by the facility staff to prevent R1’s eviction. The incident was not discussed with R1. No verbal or written warnings were issued to R1 prior to eviction. In addition, prior to serving an eviction notice to the resident, the Administrator did not submit an eviction notice to the Licensing Office for review and approval.
(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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 3
Control Number 31-AS-20220815152802
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: 08/22/2022
NARRATIVE
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Therefore, based on record reviews and interviews, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Div. 6 Ch. 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D): Exit interview was conducted, appeal rights were discussed, and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220815152802
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: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87224(f)
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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement is not met as evidenced by:
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The Administrator will review Section 87224(f) and will inform in writing explaining how they will assure to follow Title 22 Regulations with regards to following eviction procedures.

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Based on record reviews, the licensee did not comply with the section cited above as the facility did not send a written report of eviction to the licensing agency within five (05) days which poses a potential health and safety risk and violation of Personal Rights to residents in care.
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Type B
08/26/2022
Section Cited
HSC
1569.638
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§1569.683 Eviction notices; reasons for eviction contents; service (a)… a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place,
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The Administrator will review Health and Safety Code §1569.683 and will inform in writing explaining how they will assure to follow the Health and Safety Code with regards to following eviction procedures.
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witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by. The Licensee did not ensure to provide specific information regarding the steps they should take to prevent resident’s eviction. This poses a potential personal rights violation 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: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3