197610370-5-1-2025-31-AS-EMIR-DHTTV6-20250620150326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610370
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:23:23 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
12/06/2024 and conducted by Evaluator Raymond Comer

COMPLAINT CONTROL NUMBER: 31-AS-20241206091537

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: 53	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marco Villegas		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not prevent resident from entering other residents rooms-

INVESTIGATION FINDINGS:

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At 10:00 am, Thursday, 5/01/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 12/12/24. LPA met with facility Administrator, Marco Villegas, presented official CDSS badge identification, and reason for the visit was disclosed.

At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed.

To investigate the allegation, LPA received Facility resident roster, and staff roster. LPA conducted a review of Resident 1's (R1) file, and documents relevant to the investigation. Between 11:15 am and 1:30 pm, LPA interviewed the Executive Director, Residents and Staff.

[LIC 9099C]- Continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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-20241206091537

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: 05/01/2025

NARRATIVE

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Allegation: Staff do not prevent resident from entering other residents rooms- The Reporting Party (RP) alleges that staff are aware of a resident that entered Resident#1 (R1's) room on multiple occasions. However, staff neglected to address this issue.

LPA conducted interviews with Staff which revealed the following: Both the facility's Executive Director, (ED) and S1 refute the claim, stating that all residents have locks to secure their rooms are secured. Per the ED, all visitors are required to sign-in at the front desk prior to roaming the facility's premises. Per the ED, he had spoken at resident council meetings of the needs for residents to secure their rooms when unoccupied in order to better secure their personal property. R1 has a private room with no roommates. However, per the ED, R1 had a habit of leaving her room unoccupied with the door left open wide. At the time of this subsequent visit by LPA, Resident#2, (R2) whom the RP accused of wandering into others bedrooms, no longer resides at the facility. Per Staff#1, (S1) facility staff were aware that R2 liked to wander facility hallways, and that staff were vigilant to redirect R2 to common areas of the facility away from resident bedrooms. Per S1, R2 was actively sought for by staff to ensure he was not entering other resident bedrooms.
LPA conducted interviews with six (6) residents, or 10% of the current census. Six (6) out of six (6) residents interviewed state having no issues with anyone entering their rooms without their consent. Further, all residents interviewed state feeling safe, and that their personal belongings are secure.

Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff is failing to prevent residents from entering other resident's rooms. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

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