197610367-10-25-2023-31-AS-ERIS-CWXRGV-20231025130122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610367
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:02:01 PM

Document Has Been Signed on 10/25/2023 01:02 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MELROSE GARDENS		FACILITY NUMBER:	197610367
ADMINISTRATOR:	VILLEGAS, MARCO		FACILITY TYPE:	740
ADDRESS:	1007-1013 N. MARTEL AVE		TELEPHONE:	(323) 251-1426
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	31	CENSUS: 25	DATE:	10/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Marco Villegas		TIME COMPLETED:	01:15 PM

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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava arrived at the facility on 10/25/2023 at 10:30 a.m. to conduct an announced Pre-Licensing visit and met with Administrator Marcos Villegas. Entrance interview conducted with the administrator and explained the purpose of today’s visit.

Today's site visit consisted of the LPAs and administrator touring the physical plant at 10:30 a.m. inside and outside the following was observed: The facility has one main entrance being used, there are appropriate Covid-19 signs and required postings and a sign-in log in the entry lobby. The facility is a one floor building with a laundry area accessible through the outside of the building. The facility fire clearance is granted for a total capacity of thirty-one (31) bedridden residents. The facility temperature observed to be in range of 71 to 73 degrees Fahrenheit. The telephone on premises is operational and functioning. The emergency exit plan/sketch is posted on the walls throughout the building.

Kitchenette: At approximately 10:20 a.m. LPAs observed the kitchenette by the dining area to be clean. Appliances observed; sink, refrigerator and microwave appeared to be in good repair and functional. According to the administrator the facility prepares the food at their other licensed facility located across the street. The food is placed in large serving trays and transported in a large sealed cart then individually served to residents at this facility.

Bedrooms: At approximately 10:30 a.m. LPAs inspected six (6) random bedrooms all were observed to be clean and appropriately furnished and equipped with adequate lighting, bedroom furniture and linens. Extra linens, toiletries and incontinent care items sufficient for the facility capacity was observed in a hallway closet. Pull cords and intercoms systems were tested and observed to be operational and functioning. Exit doors observed to have auditory alarms and building equipped with delayed egress doors, both were tested and observed to be operational and functioning. LPA observed the call light system to be on the wall by the dining area and television area. Screen doors and window coverings observed during the time of inspection.

Continued on LIC809C

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE GARDENS	FACILITY NUMBER: 197610367
	VISIT DATE: 10/25/2023

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Bathroom: LPA observed bathrooms located inside resident bedrooms to have non-skid shower flooring and appropriate grab bars installed in shower and around the toilet. At 11:50 a.m. hot water was tested in bathrooms and measured at 115*F.

Medications: At approximately 11:15 a.m. the medication room was observed to be locked and inaccessible to residents. Medications were kept locked in a medication cart. The same pharmacy is used for most residents except for two (2) that use a different pharmacy. Medication records are kept electronically. LPA observed the First Aid Kit and Manual stored in the medication room.

Resident and Staff Records: Records are kept stored and locked in the other licensed facility 197610370 across the street. LPAs selected at random resident and staff records to review. Records were reviewed for completeness and updates.

Common areas: LPAs observed television areas to be clean and clear of clutter. LPAs observed a wheelchair elevator with last serviced date 07/12/2023 by one of the television area. LPAs observed five (5) fire extinguishers through out the facility with last serviced date 12/13/22. Administrator provided a copy of last Fire Protection Equipment Performance Report dated 07/25/2023. LPAs observed smoke/carbon monoxide detectors to be interconnected through out the facility. Dining Area was observed clean and have enough tables and chairs to sit the capacity of the facility.

Surroundings: LPAs observed the outside and surrounding area of the facility to be clean and clear from debris and obstruction. The front and back of the facility has table and chair with umbrellas and canopies for shade and is enclosed with a gated fence. LPAs observed a water fountain with water level not exceeding regulation.

Component III was conducted with the licensee and administrator on 05/12/2023. "Pre-Licensing is complete and this facility has no deficiencies."

Exit interview was conducted with Administrator Marcos Villegas and a copy of this report was provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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