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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609830
Report Date: 05/12/2023
Date Signed: 06/13/2023 02:05:15 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
01/25/2022 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20220125153218
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:
05/12/2023
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:TIME COMPLETED:
01:59 PM
ALLEGATION(S):
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Facility is not following proper COVID-19 quarantine guidance.
Facility denies visitations to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit to deliver findings on 05/11/2023. Upon arrival LPA LaQueena Lacy met Administrator Marco Villegas and explained the purpose of this visit.

#1. Facility is not following proper COVID-19 quarantine guidance

It is alleged that on or around 12/22/2022, facility residents have been in quarantine for over two weeks even though they do not have COVID-19. Initial licensing visit was conducted by the LPA Wendell Smith on 12/26/2022 at which time LPA Smith conducted an interview with the administrator Anita Csukardi. On 01/04/2023 LPA LaQueena Lacy conducted subsequent visit to continue complaint investigation. During subsequent visit, LPA Lacy requested documents relevant to the investigation on 01/04/2023 at 11:24AM. on 01/26/2022.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
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 6
Control Number 31-AS-20220125153218
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: 05/12/2023
NARRATIVE
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LPA Lacy conducted additional interviews with the new administrator Marco Villegas and staff at 11:30AM and residents at approximately 2:07PM.

Interviews with Administrator and other staff confirm that in the month of December 2022, facility was on lockdown, residents were in quarantine and no visitation was allowed.

Interviews with two (02) out of three (03) residents recall the facility being on lockdown and the residents in quarantine but do not recall the date the lockdown occurred. Residents revealed that they had to stay in their bedrooms and meals were delivered to them and the facility was not allowing visitation. During the investigation at 11:24AM on 01/24/2023 LPA observed a County of Los Angeles Public Health Covid-19 Outbreak notification that identified an outbreak had occurred and an investigation will be conducted.

Upon review of facility records, including the Department of Public Health Notification letters and e-mails received from LA County Public Health notices issued to this facility were dated 12/15/2020 and 01/14/2021. Other notices dated 01/20/21 and 12/11/22 were issued for the sister facility Melrose Gardens (Cottage) facility number 197609896 and they were under a public health order (lockdown). In addition, LPA Lacy observed an email from Los Angeles County Public Health dated 01/05/2023 which confirms that this facility did not meet the outbreak criteria reported on 12/22/2022. Based on interviews, observations and record review, there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

Deficiency cited, exit interview conducted and a copy of report and appeal rights issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/25/2022 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20220125153218

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: 41DATE:
05/12/2023
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Marcos VillegasTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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Resident are not provided with adequate meal service.
Staff did not assist resident with laundry services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit to deliver findings on 05/11/2023. Upon arrival LPA LaQueena Lacy met Administrator Marco Villegas and explained the purpose of this visit.

1. Residents are not provided with adequate meal service.

It is alleged that staff served dinner to residents that seemed to have been pre-packaged in hard plastic and the food looked very old. To investigate the above allegation, LPA Wendell Smith conducted an interview with the administrator Anita Csukardi on 01/26/2022. LPA Lacy requested documents relevant to the investigation on 01/04/2023 at 11:24AM. LPA also conducted additional interviews with the administrator Marco Villegas and other staff on 01/04/2023 at 11:30AM and residents at approximately 2:07PM.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20220125153218
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: 05/12/2023
NARRATIVE
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Interviews with three (03) out of (03) residents confirm that meals were not prepackaged and is prepared fresh and that the portions of the meals served were adequate to being in the dining room. During the time of the investigation no residents addressed any concerns with quality of meal and the services provided. During the investigation on LPA observed food being prepared for residents observed to be sufficient quality and quantity. On 05/11/2023 at 12:05PM LPA Lacy inspected the dining room during lunch hours and observed the meal served to the residents.

Based on interviews, inspection and observation, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

Exit interview was conducted and a copy of report was issued.

2. Staff did not assist resident with laundry services

It is alleged that staff did not provide laundry services to residents.

During investigation, on 01/24/2023, interviews with three (03) out of (03) residents confirm that laundry services were completed during the outbreak with no disruptions, although the days may change but the laundry is done twice a week. Interviews with staff confirm that laundry is done twice a week for residents, but they do laundry every day. On 01/24/2023 at 2:45PM while conducting a facility inspection, LPA observed staff in the laundry room washing resident clothing. The clothing was separated in the bags per resident and is returned to each resident after it’s completed. Based on interviews, inspection, and observations there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20220125153218
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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87468(a)
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87468 Personal Rights(a)Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to... This requirement was not met as evidenced by:
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Licensee will ensure to review Title 22 regulation 87468 Personal Rights to ensure residents rights are not viloated. Licensee will have an in-service on residents rights and provied in-service documentation to LPA by POC due date.
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Based on LPA interviews and observations, the facility failed to ensure that the facility followed proper county public health order, which poses a potential Health and safety and personal rights risk to persons 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: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20220125153218
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: 05/12/2023
NARRATIVE
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2. Facility denies visitations to residents in care

It is alleged that family visitations were denied. To investigate the above allegation, on 01/26/22, LPA Wendell Smith conducted an interview with administrator Anita Csukardi and the administrator admitted to LPA Smith that “as of right now no visits”.

On 01/04/2023 LPA Laqueena Lacy’s Interviews with two (02) out of three (03) residents recall the facility was not allowing visitation. During the investigation LPA Lacy reviewed Licensing Records and observed a 15-day Covid-19 follow up contact call with the administrator on 01/25/2022, where she stated, “they are working on reopening visitation”. A review of an email from Los Angeles County dated 01/05/2023 confirms that the facility did not meet the outbreak criteria reported on 12/22/2022.

Overall investigation revealed that although the facility was not meeting Covid 19 outbreak criteria, facility was not allowing vitiations. Based on interviews, and record review, there is enough evidence to prove that the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

Deficiency cited, exit interview conducted and a copy of report and appeal rights issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6