197609724-6-17-2024-31-AS-RCOR-D6C74C-20240617211943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609724
Report Date: 06/17/2024
Date Signed: 06/17/2024 09:24:29 PM

Document Has Been Signed on 06/17/2024 09:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELROSE CHATEAU		FACILITY NUMBER:	197609724
ADMINISTRATOR:	VERGARA, KANDICE		FACILITY TYPE:	740
ADDRESS:	819 N POINSETTIA PL		TELEPHONE:	(310) 413-8717
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	12	CENSUS: 10	DATE:	06/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Alexcis Peralta		TIME COMPLETED:	03:30 PM

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	On 06/17/24, 10:05 AM, Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual visit at this facility. LPA met with Facility Administrator, Alexcis Peralta , and reason for the visit was disclosed. Facility is licensed as a single-story residence, fire clearance for twelve (12) non-ambulatory, of which, twelve (12) may be bedridden. Hospice waiver for twelve (12). Facility has six (6) shared resident bedrooms and seven (7) bathrooms, of which, one bathroom is available for use by both residents and staff. At the time of this inspection, the Facility occupied eight (8) ambulatory residents, and two (2) non-ambulatory residents, none of which are bedridden. Currently, none of the Facility's residents are receiving hospice care. At 10:40 AM, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Hand sanitizer, gloves, and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displayed a setting of 77.°F., within the required range. An approved Mitigation and Infection Control plan is on file. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 6/14/2024. [LIC 809C Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE CHATEAU	FACILITY NUMBER: 197609724
	VISIT DATE: 06/17/2024

NARRATIVE

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Fire Detection/Protection system Multiple smoke alarms and Carbon Monoxide sensors are installed throughout the facility, hardwired, and interconnected. Smoke and Carbon monoxide detectors were tested and function properly. LPA observed a fire extinguisher located in the kitchen area, with maintenance service date: 4/11/2024.

Kitchen: At 11:30 AM, LPA observed kitchen as clean, equipped with functional stove, multiple appliances, with adequate supply of perishables and non-perishable food. Kitchen cabinets contain emergency dry food, can goods, condiments, dishes, plastic, paper goods and utensils. Food is observed as properly stored and refrigerated. Knives and sharps are secured and inaccessible to residents.

Medications are stored in secured medications carts located in a room adjacent to the dining area, and are inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored in the medication cart.

Laundry area is located in a separate building and and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

Commons: LPA observed all common areas of the facility, including the living room and resident dining area adjacent to the kitchen. LPA observed common areas to be clean, with adequate furnishings in good repair.

Bedrooms At 12:15 PM, LPA observed bedrooms as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and night stand. All bedrooms are equipped with a signaling system for Residents to request Staff assistance. Signaling system was tested; Staff responded to signal is less than three minutes.

Outdoor (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. Multiple sheds in the outdoor area contain tools, supplies, and PPE. All Sheds were observed as locked and inaccessible to Residents. All trash cans were covered. There are no bodies of water in the facility.

[LIC 809C Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE CHATEAU	FACILITY NUMBER: 197609724
	VISIT DATE: 06/17/2024

NARRATIVE

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Resident records: LPA observed records stored in a locked and secured records room, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: LPA observed records stored in a locked and secured records room, inaccessible to residents. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility representative, Administrator Alexcis Peralta.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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