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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609724
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:42:38 PM

Document Has Been Signed on 05/20/2025 02:42 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 CHATEAUFACILITY NUMBER:
197609724
ADMINISTRATOR/
DIRECTOR:		VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:819 N POINSETTIA PLTELEPHONE:
(310) 413-8717
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 12CENSUS: 9DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Alexcis PeraltaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 05/20/25, 10:35 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; one bathroom is available for use by both residents and staff. At the time of this inspection, one (1) resident is non-ambulatory; no bedridden. None of the facility's residents are receiving hospice care at this time.

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. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displayed a setting of 71.°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 3/29/2025.



[LIC 809C-Continued]
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/20/2025
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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: 4/10/2025.

Kitchen: At 11:15 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 two (2) medications carts, located in a room adjacent to the dining area. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored in the medication cart. However, upon inspection by LPA, one of the medication carts was found unlocked, which presents a potential for unauthorized access to residents and visitors.



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 12:00 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.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 116.5°F. Within the required range. Hand towels are not shared.

[LIC809-C Continued]

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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: 05/20/2025
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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.

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.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2025 02:42 PM - It Cannot Be Edited


Created By: Raymond Comer On 05/20/2025 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE CHATEAU
FACILITY NUMBER: 197609724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored...Centrally stored medications shall be kept in a safe and locked place that is not accessible to person other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, one of two medication carts were unlocked and accessible to residents., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Administrator will conduct in-service with all staff on centrally stored medications, and submit proof of completed safety awarenes training to LPA by May 30, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Raymond Comer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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