197610370-2-29-2024-31-AS-MVAO-D3XS6X-20240402133640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610370
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:29:28 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
02/21/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240221085535

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:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Marco Villegas, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from handling another resident in a rough manner
Staff did not prevent resident from making threatening comments towards another resident
Staff are not providing a comfortable environment for resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:45 AM, Licensing Program Analysts (LPAs) Huma Rahimi, DeLaCerra, Leizl, and LPM Naira Margaryan conducted an unannounced initial complaint visit. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit.

During course of the investigation, at 10:50 am, LPAs requested resident and staff roster. At 10:55 am, LPAs requested and reviwed copies of pertinent records which include, but not limited to Admission Agreement, Identification Emergency Sheet, Physician Report, Pre-placement Appraisal, Subsequent Appraisal, Incident Report, and Facility Notes, relevant to the investigation. At approximately 11:30 am, LPA conducted a physical plant tour. Between 12:00 PM – 1:00pm, LPA conducted an interview with the Administrator, four (04) staff; two (2) caregivers and two (2) med techs and seven (7) residents.

Continue on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20240221085535

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: 02/29/2024

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

Staff did not prevent resident from handling another resident in a rough manner
Staff did not prevent resident from making threatening comments towards another resident
Regarding the above allegations: It was alleged that the facility resident #2 (R2) verbally and physically abused Resident #1 (R1).
Staff revealed they always try to prevent residents form being verbally abusive and/or being rough to other resident(s. They try to intervene as soon as possible to prevent inappropriate interactions. R1 and R2 residing in the same room (please note R1 and R2 are married couple) Staff revealed that on 02/17/24, there was an incident of verbal and physical abuse between R1 and R2. Staff was alerted by R1 and they immediately intervene to assist residents. R2 was removed from the room and placed to another room.
Staff intervention prevent the situation from escalating. Interview with R1 verified the information received from staff. Furthermore, R1 stated that they feel safe in the facility and staff is assisting them all the time.
In addition, interviews with seven (7) residents confirmed that the staff are always available to prevent any kind of incident from happening. Based on information obtained through interviews and observation, it was concluded that although the incident between 2 residents occur, the staff intervene and took all required steps to assist as needed. Therefore, this allegation is unsubstantiated at this time.

Staff are not providing a comfortable environment for resident
It was alleged that the R1 was scared from R2 and does not want to be in the same room with R2 and staff is not moving R2.
Staff revealed that they were not able to remove R2 to different room permanency, because R1 and R2 are married couple and wanted to be in the same room. However, on 02/17.24, when R2 was aggressive toward R1, they took an immediate action by removing R2 from the room and transferring them to a different room. R1 verified the information revealed from staff.
A Review of resident records revealed that R2 has health conditions triggering aggressive behavior which may require close supervision by facility staff. The information revealed from records supported the information received from staff.
Based on inspection, observation, and record review there is no sufficient information to support the allegation. Therefore, this allegation is deemed Unsubstantiated.

No immediate health and safety issues were noted during this visit.
Exit interview was conducted and copy of report was issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
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

LIC9099 (FAS) - (06/04)

Page: 2 of 2