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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609830
Report Date: 11/02/2021
Date Signed: 12/06/2021 05:46:50 PM

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: 41DATE:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Anita Csukardi, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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This case management visit was conducted in conjunction with complaint investigation to address the deficiencies unrelated to the complaint. During the complaint investigation, on 11/02/2021 it was discovered that the facility did not submit a timely incident report to CCLD for a fall incident of resident #1 (R1).

Therefore, Under Title 22, Division 6, Chapter 8 following citation will be issued and recorded on LIC809d

No other health and safety hazard were noted during this visit. Exit interview was conducted and a copy of report issues.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2021
Section Cited

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REPORTING REQUIRMENTS. (a)(2)
Occurrences, such as … major accidents which threaten the welfare, safety or health of residents, personnel, or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency…. This requirement is not met as
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evidenced by. The Licensee did not report the incident that threatens health and safety of the resident. R1’s fall incident was not reported to the Licensing office. This poses a potential health, safety and personal right risk 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) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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