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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610367
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:33:50 PM

Document Has Been Signed on 12/12/2024 02:33 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE GARDENSFACILITY NUMBER:
197610367
ADMINISTRATOR/
DIRECTOR:		VILLEGAS, MARCOFACILITY TYPE:
740
ADDRESS:1007-1013 N. MARTEL AVETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 31CENSUS: 30DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marco VillegasTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 12/12/24, 9:45 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Marcos Villegas, and reason for the visit was disclosed.

Facility is licensed as a single-story building. Fire clearance approved for thirty-one (31) non-ambulatory residents. Bedridden cleared in thirty-one residents. Hospice waiver approved for thirty-one (31).
Currently, there are two (2) residents receiving hospice care services; no bedridden at time of visit.

At 10:15 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility.
Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 75.0°F; within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on September 25, 2024

Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested and works properly. Two (2) fire extinguishers were observed on opposite ends of the hallway; extinguishers last serviced on December 24, 2023. Evacuation routes are clearly labelled and posted throughout the facility. Fire drill last conducted September 25, 2024.

[LIC 809-C] Continued-
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE GARDENS
FACILITY NUMBER: 197610367
VISIT DATE: 12/12/2024
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Kitchen: At 10:45 am, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen;knives and sharps are inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas.

Medications: Medication room is located next to the facility entrance; LPA observed room as locked and inaccessible to residents. Medications are properly labeled, and stored in secured medication carts. Medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room.

Laundry: At 11:12 am, LPA observed the laundry room, located in outdoor storage compartment. Laundry room, detergents, cleaning supplies, and other toxins, are secured in locked compartment area and inaccessible to residents. Laundry area is clean and clear from obstruction.

Commons: Activity room, and dining room, observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

Bedrooms: At 11:35 am, LPA observed random resident bedrooms and bathrooms for safety, privacy, and comfort. Resident rooms were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 113.5°F; Within the required range.

Outdoor (rear courtyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

Resident records: At 12:15 pm, LPA observed records room, located in Administrator's office, as secured and inaccessible to residents. A total of three (3) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.



[Continued on LIC 809-C]
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELROSE GARDENS
FACILITY NUMBER: 197610367
VISIT DATE: 12/12/2024
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Staff records: At 12:40 pm, LPA observed records room, located in Administrator's office, as secured and inaccessible to residents. A total of three (3) Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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