<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610367
Report Date: 05/23/2025
Date Signed: 05/23/2025 02:56:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
05/05/2025 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20250505152734
FACILITY NAME:MELROSE GARDENSFACILITY NUMBER:
197610367
ADMINISTRATOR:VILLEGAS, MARCOFACILITY TYPE:
740
ADDRESS:1007-1013 N. MARTEL AVETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:31CENSUS: DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Marco VillegasTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not properly safeguarding medications-
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 8:45 am, Friday, 5/23/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 05/14/25. LPA met with facility Administrator, Marco Villegas, presented official CDSS badge identification, and reason for the visit was disclosed.

At 9:05 am, LPA conducted a physical plant tour; no health and safety issues were observed.

To investigate the allegation(s), LPA received Facility resident roster, and staff roster. LPA interviewed the Administrator, staff, and residents.

[LIC 9099C]- Continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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-20250505152734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2025
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
26
27
28
29
30
31
32
Allegation: Facility staff are not properly safeguarding medications - The Reporting Party (RP) alleges that a staff member left their child in the medications room unattended during their scheduled work shift.

LPA conducted an interview with the Administrator, which revealed the following: Per the Administrator, he allowed the staff member (S1) in question to let their child sit in the medications room. "It was a Sunday, and S1 did not have anyone to watch over the child that day. He [the child] was sitting in S1's vehicle and it was a very hot day, so I allowed S1 to bring her child in the medications room." Per the Administrator, "All medications are securely locked in medication carts and overhead cabinets, so there was no way for unauthorized persons to access any medications."
LPA conducted an observation of the medications room which revealed the following: Door to medications room was locked and inaccessible to residents. Inside the room, all medications were witnessed as securely locked in medication carts and overhead cabinets. However, the Administrator admits that non-authorized persons were allowed access in the medications room.

Based on the information LPA obtained through observation, interviews with the Administrator, staff, residents, the allegation that facility's medications were not properly safeguarded is Substantiated.

Deficiency is cited on the LIC 9099-D page. Exit interview conducted. Appeal rights discussed.
Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250505152734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
All staff will complete in-service training regarding access policy to medications room within ten days of this citation. Licensee will provide statement that moving forward, medication room access policy will comply with regulations. Evidence of completion to be submitted to LPA as POC.
8
9
10
11
12
13
14
Based on LPA interviews with the Administrator and Staff, the licensee failed to ensure that the facility's medication room was inaccessible to persons other than athorized personnel which posed an immediate health risk to residents in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3