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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609830
Report Date: 07/06/2021
Date Signed: 07/12/2021 10:21:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE GARDENS LA, LLC.FACILITY NUMBER:
197609830
ADMINISTRATOR:DENISE ROMEROFACILITY TYPE:
740
ADDRESS:960 N MARTEL AVETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:100CENSUS: DATE:
07/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anita CsukardiTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy conducted unannounced Case management visit to the facility. LPA met with the Executive Director and explained that this visit was conducted to address the issues previously noted during complaint investigation visit conducted on 05/21/2021,

On 05/21/2021 Licensing Office completed an investigation of the complaint alleging “unlawful eviction”; (Complaint Control # 31-AS-20201215114640).

Upon further review the 30-day eviction notice, served to R1, it was noted that the notices did not contain required information as outlined in Title 22 Regulations.
· The eviction notice for the month of November 2021, identifies that the notice was given for nonpayment of rent. However, the notice does not include the correct amount of back due payments.
· The 30-day eviction notice(s) did not include the address of the California State Long-Term Care Ombudsman (LTCO) identified as one of the available resources to assist resident.

At the time of this visit the following citation was issued and recorded on LIC809D.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE GARDENS LA, LLC.
FACILITY NUMBER: 197609830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited

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1569.682(a)(2) (A);(F) Transfer of residents; A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility….Provide each resident/ resident’s responsible with a written notice before the intended eviction. The notice shall include the following The reason for the eviction,
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with specific facts and the contact information for the LTCO, including address and telephone number. This requirement was not met as evidenced by; The Licensee did not ensure that eviction notice contains specific facts & LTCO’s address. 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
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