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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610370
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:15:56 PM


Document Has Been Signed on 02/29/2024 03:15 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:
197610370
ADMINISTRATOR:VILLEGAS, MARCOFACILITY TYPE:
740
ADDRESS:960 N. MARTEL AVENUETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:100CENSUS: 54DATE:
02/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:MarcoVillegas TIME COMPLETED:
03:30 PM
NARRATIVE
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This case management visit was conducted in conjunction with complaint investigation to address the deficiencies unrelated to the complaint.
While conducting complaint investigation at 10:45am LPAs DelaCerra, and Rahimi and LPM Margaryan observed deficiencies unrelated to the complaint.
1.While entering to the parking lot the buzzer was not working. LPM had to call the Administrator to have staff to open the gate.
1, LPAs and LPM observed the trash containers blocking the exit door next to the gate.
2.There were cigarette buts everywhere.
3.The parking lot that was also used as an outside recreational/smoking area for the residents, was obstructed with the old and broken furniture and some of the pieces had sharp corners that could pose hazard to the residents’ health, safety and wellbeing.
4.The whole parking lot including recreational areas for the residents was not mantined as required.
At the time of this visit the Licensee Representative arrived at the facility and LPM Margaryan discussed all noted issues.
The Licensee representative arranged to remove all broken furniture and clean up the whole parking lot today 02/29/2021.
Based on inspection and observation, the following deficiency will be cited and recorded on LIC809D.
No other issues noted at the time of this visit. Exit interview is concuted, appeal rights were discussed and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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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Document Has Been Signed on 02/29/2024 03:15 PM - It Cannot Be Edited

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: 197610370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. .
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The Licensee contacted appropriate agencies to remove broken furniture and clean up the backyard.
Therefore, this citation is cleared during this visit.
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This requirement is not met as evidenced by. Licensee did not ensure that facility parking lot and outside recreational area are clean and free of obstructions. This possess potential health and safety hazard to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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