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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609830
Report Date: 11/23/2022
Date Signed: 03/01/2023 11:12:13 AM

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
11/08/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20221108124742
FACILITY NAME:MELROSE GARDENS LA, LLC.FACILITY NUMBER:
197609830
ADMINISTRATOR:MARCO J VILLEGASFACILITY TYPE:
740
ADDRESS:960 N MARTEL AVETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:100CENSUS: 42DATE:
11/23/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marco VillegasTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility has pests
Staff do not distribute resident's medications as prescribed
INVESTIGATION FINDINGS:
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This is an amendment to the report delivered on 11/23/2022.
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with the Executive Director, Marco Villegas, and discussed the reason for the visit.

--- Facility has pests.
It was alleged that resident(s) have cockroaches in their bathroom. To investigate the allegation, on 11/16/2022 at 10:15 AM LPA made observations during a physical plant tour, at 11:00 AM, LPA randomly selected and interviewed 10 % of the residents present at the facility. At 12:00 PM, LPA interviewed staff. On 03/01/2023 at 10:00am, LPA requested documents. During the physical plant tour, LPA did not observe any cockroaches, the droppings or eggs of cockroaches in Residents rooms, including the rooms and bathrooms of the residents interviewed during investigation.
(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20221108124742
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 GARDENS LA, LLC.
FACILITY NUMBER: 197609830
VISIT DATE: 11/23/2022
NARRATIVE
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During interviews with residents, at least two (02) Resident; Resident #1 (R1) and Resident #3 (R3) stated that they have seen cockroaches at the facility. During interviews with staff, they all stated that although they have never seen any cockroaches or any other pests, but the incidents were reported to them verbally by residents. Documents revealed that the facility scheduled fumigations in October and November 2022 and as per Executive Director R1’s and R3s rooms were included in the fumigation schedule.

Based on interviews and record review, there is a sufficient corroborating information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

--- Staff do not distribute resident's medications as prescribed.

It was alleged that the facility is not ordering and administering medications timely. To investigate the allegation, on 11/16/2022 at 10:15 AM, LPA made observations during a physical plant tour, at 10:50 AM, LPA requested records, at 11:00 AM, LPA interviewed residents and at 12:00 PM, LPA interviewed staff. LPA observed that R1’s bubble pack was emptied from the start date 11/09/2022. A review of the facility’s Medication Administration Records revealed that there were dates missing in the month of November 2022 indicating that the medications were not given to R1. Staff #2 (S2) stated that there are times when the medication deliveries are slightly delayed, but it is not a result of the facility ordering the medication late and it does not delay the administration of medications. During interviews, resident #1 (R1) stated that they are not ordering and administering their medications timely and recalls that the facility missed at least one day of medications in the month of November 2022.



Based on interviews and record review, there is a sufficient corroborating information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards observed during the visit.
Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20221108124742
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 GARDENS LA, LLC.
FACILITY NUMBER: 197609830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2022
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care Services. (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (a)(4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will submit a detailed written plan notifying the department what steps will be taken to prevent medication errors from occurring with Resident 1 and other residents.
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This requirement is not met as evidenced by:

Based on interviews and record review, the licensee failed to ensure that R1 was given their medication as prescribed which posed an immediate health risk to residents in care.
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Type A
11/28/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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Although the facility hired a pest control company to service the facility for insects, as a POC, the Administrator will submit a written letter stating that they have reviewed Title 22 Div. 6 Ch. 8 of the CA Code of Regulations 87303(a) and, going forward, will adhere to the regulation.
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Based on interviews, two (02) out of three (03) residents stated they've encountered cockroaches at the faciltiy. This poses an immediate health and safety risk to the 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) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3