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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609830
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:50:32 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
01/27/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20220127145419
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: 35DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ayalla Levi - Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility has insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with Executive Director Ayalla Levi and explained the reason for the visit.

LPA conducted physical plant tour at 11:34 AM, requested copy of facility documents relevant to the investigation at 11:45 AM and interviewed staff and residents between 12:00 PM to 2:00 PM. It was alleged that the facility has only one caregiver between the hours of 8:00 PM to 11:00 PM for a facility with the capacity of 72 residents. LPA record review on 01/31/22 at 10:25 AM and today at 10:45 AM revealed that the facility has always two (2 ) care staff scheduled during PM (3:00 PM to 11:00 PM). However, LPA interview with five (5) randomly selected residents or more than 10% of current census revealed that three (3) out of five (5) residents believe that the facility has staffing shortage. LPAs interview with five (5) care staff also revealed that all of them believed that the facility is short staff especially during the AM (7:00 AM to 3:00 PM) shift (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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-20220127145419
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: 02/17/2022
NARRATIVE
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(continued from LIC 9099)

Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights, discussed and given.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220127145419
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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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Per the administrator, the facility has already hired new care staff and will start by Monday LPA checked the person and the person is already fingerprint cleared and associated at the facility.

Cleared during visit.
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Based on LPA interview with staff and residents, the licensee did not ensure that the facility has sufficient staffing to meet residents need. This poses a potential health and safety risks 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: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3