197609830-12-15-2022-31-AS-ADUA-CM5SEZ-20221215124933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609830
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:50:17 PM

Document Has Been Signed on 12/15/2022 12:50 PM - It Cannot Be Edited

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:	MARCO J VILLEGAS		FACILITY TYPE:	740
ADDRESS:	960 N MARTEL AVE		TELEPHONE:	(323) 876-1746
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	100	CENSUS: 36	DATE:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Marco Villegas		TIME COMPLETED:	09:52 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Abeye Duguma met with the administrator, Marco Villegas, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00 AM and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during the visit. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the gated patio in front of the building. The facility has sufficient stock of PPE. The facility has thirty-eight (38) bedrooms, each with their own bathrooms. The facility is fire cleared for one hundred (100) non-ambulatory of which twenty-eight (28) may be bedridden. The facility is currently occupying thirty-three (33) non-ambulatory residents. The patio of the facility has outdoor furniture, with a covered shaded area for clients. The facility does not have a swimming pool/body of water. The facility has three different laundry rooms, one in the basement (commercial grade), one on the ground floor and the other is located on the first floor. Laundry detergents, cleaning agents and other toxins are stored in the basement. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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
	VISIT DATE: 12/15/2022

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Knives and sharps are observed to be locked in a kitchen drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 80°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility and last inspected 12/13/2022. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Clients purchase their own hygiene product. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.9°F. Towels and washcloths are not shared. There was enough clean linen available in the linen room on the second floor. Medications: LPA observed medication to be locked and inaccessible to residents in the Med Tech room located on the first floor. There is a complete first aid kit located inside the Med Tech room and kitchen.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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