197609830-12-22-2021-31-AS-NMAN-CA82GV-20211230162346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609830
Report Date: 12/21/2021
Date Signed: 12/22/2021 08:27:20 AM

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
10/28/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20211028134706

FACILITY NAME:	MELROSE GARDENS LA, LLC.		FACILITY NUMBER:	197609830
ADMINISTRATOR:	DENISE ROMERO		FACILITY TYPE:	740
ADDRESS:	960 N MARTEL AVE		TELEPHONE:	(323) 876-1746
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	100	CENSUS: 35	DATE:	12/21/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anita Csukardi, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not communicating with family regarding resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 symptoms. LPA met with Anita Csukardi, Executive Director (ED) and explained the purpose of this visit. It was alleged that resident #1’s (R1’s) conservator ordered the facility staff not to contact R1’s family. To investigate these allegations, on 11/02/2021 at 2:00pm, LPA spoke with ED, facility staff, the conservator and other parties. Interviews revealed that the conservator never ordered the facility not to communicate with R1’s family via-email or otherwise. The request to communicate with only one person regarding R1’s care in the facility was made by facility staff and the conservator agreed to limit e-mail communication with the family to only once per week. At 3:00pm LPA requested and reviewed R1’s facility files and other relevant documents. After careful review, it was determined that both the conservator and the facility did not have the right to restrict any type of contact between R1 and R1’s family and/or between the facility and R1’s family. Based on the information from interviews and records review, the allegation is SUBSTANTIATED at this time.No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211028134706

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: 12/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/31/2021 Section Cited CCR 87468.2	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.	1 2 3 4 5 6 7	The Executive Director will provide a written plan of action explaining how the staff will adhere to residents' personal rights, training will be provided to all facility staff, information regarding the training will be part of the documentation and submit a copy of the training by 12/31/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: The licensee did not ensure that resident's family was informed about the resident, ED requested to have one point of contact, which was the conservator.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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