197610370-5-12-2023-31-AS-LQLY-CRRTVJ-20230512150401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610370
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:04:13 PM

Document Has Been Signed on 05/12/2023 03:04 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		FACILITY NUMBER:	197610370
ADMINISTRATOR:	VILLEGAS, MARCO		FACILITY TYPE:	740
ADDRESS:	960 N. MARTEL AVENUE		TELEPHONE:	(323) 876-1746
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	100	CENSUS: 41	DATE:	05/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Marcos Villegas		TIME COMPLETED:	03:07 PM

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) LaQueena Lacy arrived at the facility on 05/12/2023 at 10:07AM 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, is to inspect the facility and ensure compliance with rules and regulations California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of the LPA and administrator touring the physical plant at 10:25AM inside and outside the following was observed: The facility has one main entrance being used, there are Covid-19 prevention signage (wear a mask, coughing etiquette) posted. Upon entry staff checked LPA temperature. The facility is a two-story building with a basement and a detached garage. The facility fire clearance is granted for seventy-two (72) non-ambulatory and twenty-eight (28) bedridden residents. Fifteen (15) bedridden bedrooms on the first floor are granted for bedridden resident. The facility temperature observed to be in range of 74 to 77 degrees Fahrenheit(F).

Kitchen: At 10:26AM LPA observed the kitchen to be clean and free from obstruction. Appliances observed

to be in good repair and functional. Sharps are stored inaccessible to residents which they do not have access to the kitchen. Refrigerated and frozen foods were stored at proper temperatures with sufficient amount of perishable and non-perishable food properly stored. LPAs observed the refrigerators and freezers to be stocked with a variety food. At 10:32AM LPA observed a pantry storing dry food, spices, and canned goods as well as the emergency food supply.

Bedrooms: At 10:48AM LPA inspected six random bedrooms all were observed to be clean and appropriately furnished and equipped with adequate lighting and bedroom furniture. 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. Screen doors and window coverings observed during the time inspection.

Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE GARDENS	FACILITY NUMBER: 197610370
	VISIT DATE: 05/12/2023

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

Bathroom: At 10:48AM LPA observed bathrooms located inside resident bedrooms to have non-skid mats and appropriate grab bars installed in shower and around toilet. At 10:48AM hot water was tested in bathrooms and measured in range of 113.6 to 115.6 degrees F. The telephone on premises is operational and functioning. The emergency exit plan/sketch is posted on the walls throughout the building first and second floor.

Medications: At 11:22AM the medication room was observed to be locked and inaccessible to residents clean and free from debris or obstruction. Medications were separated by residents, kept in plastic containers and trays. At 11:38AM LPA observed the First Aid Kit and Manual stored in the medication room and kitchen.

Laundry Room, dining room and common areas: At 11:49AM LPA observed the basement locked and inaccessible to residents to be storing laundry supplies, cleaning supplies, toxins and incontinent supplies, staff files, activity supplies, decoration, and PPE. The facility also has an industrial laundry area.

At 11:57AM LPA 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 owing for lounging and a cover patio area that’s enclosed with a gated fence. No bodies of water observed on the property.

At 12:10PM the common areas (living room, dining areas and library) were appropriately furnished and lighting is adequate and comfortable furniture for seating which was observed to be in good repair. The fire extinguishers are located on the wall throughout the facility inside and outside to have a service tag dated for 12/13/2022. At 12:25PM the facility carbon monoxide alarms were tested and observed to be operational and functioning properly. The facility provided a Los Angeles Fire Department Fire Protection Equipment Performance Report dated 10/11/2022 to have passing results. At 2:38PM LPA observed the call light system to be stored at the receptionist desk that makes an alarming noise when the cord is pulled and when the intercom is used it is direct contact to the receptionist and sound is maintained until the call is responded to and reset. Component III was conducted with the licensee at 2:41PM.

Component III was conducted with the licensee at 2:41PM. The Facility is currently not in compliance with Title 22 Regulations at the time of the visit..During the time of the inspection LPA observed delayed egress doors on the 1^st and 2^nd floor exit doors which the fire clearance dated 12/08/2022 does not identify clearance for delayed egress. This report will be forwarded to the Centralized Application Bureau (CAB), once a fire clearance has been obtained and approved for the facility the pre-license will be reviewed for approval.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE GARDENS	FACILITY NUMBER: 197610370
	VISIT DATE: 05/12/2023

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

Component III was conducted with the licensee at 2:41PM.

The Facility is currently not in compliance with Title 22 Regulations at this time. During the time of the inspection LPA observed delayed egress doors on the 1^st and 2^nd floor exit doors which the fire clearance dated 12/08/2022 does not identify clearance for delayed egress. This report will be forwarded to the Centralized Application Bureau (CAB), once a fire clearance has been obtained and approved for the facility the pre-license will be reviewed for approval.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3