197610370-11-19-2025-31-AS-MGFS-DVQSFV-20260706135054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610370
Report Date: 11/19/2025
Date Signed: 11/19/2025 04:11:09 PM

Unsubstantiated

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
07/18/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250718135547

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: 54	DATE:	11/19/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Joseph "Yossi" Wieder - Executive Director		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff are not ensuring residents are provided with a safe environment.
Staff speak inappropriately to residents in care.

INVESTIGATION FINDINGS:

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At 12:15 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit at this facility to continue the investigation on the above allegations. LPA met with the Executive Director, Joseph "Yossi" Wieder and LPA explained the reason for the visit. An entrance interview was conducted.

To investigative the allegations LPA Rios conducted an initial visit on 07/22/2025 and requested a copy of the resident roster and personnel report. On 7/22/2025 at approximately 12:50 p.m., LPA initiated a physical plant tour. Between 1:10 p.m. and 2:00 p.m., LPA conducted interviews with two (02) residents, Resident #1 (R1) and Resident #2 (R2). Between 3:00 pm and 4:00 pm, LPA interviewed two (02) staff of which one was the Wellness Director, Nancy Adam and the Administrator, Marco Villegas. At 4:00 pm, LPA requested copies of pertinent information relevant to the investigation which include, but is not limited to residents' physician’s reports, appraisal/needs and services plans and progress notes.
(Continue to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250718135547

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: 197610370
	VISIT DATE: 11/19/2025

NARRATIVE

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(Continued from LIC9099)During today's visit from 12:24 p.m. to 2:00 p.m., LPA Rios interviewed two (2) staff and four (4) residents, Resident #3 through Resident #6 (R3-R6). LPA obtained copies of the facility's resident roster, Personnel Report (LIC500) and R1's hospital discharge paperwork from 08/28/2025 and skilled nursing discharge paperwork from 10/23/2025.

Allegation: Staff are not ensuring residents are provided with a safe environment. It was reported that Resident #2 (R2) verbally attacked and later physical confronted, Resident #1 (R1) and when the abuse was reported to the administrator no action was taken. LPA's interview with R1, confirms the allegation stating R2 would say derogatory statements towards them about their appearance. R1 reports that R2 had knocked off R1's personal property from their dresser and slammed a door on R1's foot. According to R1 they reported the incidents to management and nothing was done. Interview with R1 and R2 each indicated the other as the perpetrator and instigator. However R2 admits they were experiencing mental health concerns that were addressed and are aware they could have been difficult to live with. R2 denies becoming physically confrontational with R2 except for knocking things off of R1's dresser. Interview with the administrator at the time Marco Villegas and Wellness Director Nancy Adams denied physical confrontation had been reported but they were aware that R1 and R2 were both not getting along. According to the Wellness Director, had they known a physical confrontation had happened they would have acted immediately and moved residents to different rooms. The administrator stated both residents were asked separately if they would move to a different room but they both declined. R1 and R2 corroborate management had asked if they would like to move to another shared room and they declined. Interview with staff on 07/22/2025 and 11/19/2025 corroborate R1 and R2 were having issues. Staff interviews indicated R1 was being argumentative with R2 and had not witnessed it the other way around. Staff also deny witnessing physical confrontations. LPA's interview with four (4) residents on 11/19/2025 indicated they feel staff is ensuring a safe environment. R1 left the facility on 08/27/2025 and returned on 10/24/2025 and agreed to move to a different room.

Based on LPAs interview, there is corroborating evidence that R1 and R2 were having issues, however the facility offered resident's to move rooms and they declined at the time. Therefore the allegation staff are not ensuring residents are provided with a safe environment is Unsubstantiated at this time.

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SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250718135547

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: 197610370
	VISIT DATE: 11/19/2025

NARRATIVE

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Allegation: Staff speak inappropriately to residents in care. Regarding the allegation is was reported the Administrator and the Wellness Director at the time threatened to "kick out" Resident #1 (R1) if they reported the abuse. Interview with R1 confirmed the allegation stating after no action was taken regarding R2 being verbally and physically abusive towards them they stated they would report it to Adult Protective Services (APS). According to R1, management stated they would evict them for causing problems. Interviews with the administrator and staff deny the allegation. Interview with the Wellness Director indicated R1 let them know she sent a report after she had already made it to APS and not before. LPA's Interview with staff indicated they felt management act on issues concerning residents and they had not witnessed management make threats. Staff also indicated residents had not made complaints regarding staff making inappropriate statements. LPA's interview with Resident #2 (R2) on 07/22/2025 and four (4) residents on 11/19/2025 indicated they feel they could report to to staff and management if they had a serious concern. Residents also denied staff speak inappropriately to them.

Based on LPA interviews, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time.

No immediate health or safety issues observed. Exit interview conducted. Copy of report provided.

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SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

LIC9099 (FAS) - (06/04)

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