197609830-12-6-2021-31-AS-NMAN-CA82GW-20211230162346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609830
Report Date: 12/06/2021
Date Signed: 12/06/2021 05:44:05 PM

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: 33	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Anita Csukardi, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident had multiple falls while in care.
Facility does not have sufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Abeye Duguma conducted subsequent complaint visit to the facility. LPA met with the Administrator and explained the purpose of this visit.
--- Resident had multiple falls while in care
It was alleged that resident #1 (R1) had multiple falls while in care. R1 fell 10/27/2021 in the afternoon at 4:30pm and the granddaughter got an email at 6:45pm and didn't see it until morning that R1 fell and went to the hospital. During this investigation, on 11/02/2021 at 2:00pm, LPA interviewed the Administrator, who reported that R1 had one unwitnessed fall incident on 10/24/2021, R1 had no apparent injury. However, the staff sent R1 to the hospital for further evaluation. R1 returned to the facility the following day 10/25/2021, at which time the facility placed a sensor mat on the floor near the bed, R1 started to received hospice services and passed away on 10/28/21. On 12/06/2021 at 11:15am, LPA Duguma reviewed facility records and noted that the information revealed from the records are verifying the information revealed from the interviews. Based on the interview and record review there is not enough supporting information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.
(Cont on LIC 9099-C)

Unsubstantiated

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: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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
	VISIT DATE: 12/06/2021

NARRATIVE

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--- Facility does not have sufficient staffing.
It was alleged that facility has two people at night and three people during the day for 50 residents.
During this investigation, on 11/02/2021 at 2:00pm, LPA interviewed the Administrator and she reported that currently there are eleven (11) residents residing in memory care. For 11 residents, there are three (03) direct care staff per shift; two (02) care staff and one (01) Med Tech. Administrator also reported that staff check the residents every two hours. A review of the staff schedule conducted on 12/06/2021 at 12:45pm, verified the information received from the interviews. LPA also witnessed sufficient staffing in Memory Care during facility visit. Based on the interview and record review there is not enough supporting information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

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