197610370-2-29-2024-31-AS-MVAO-D3XRHH-20240402130221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610370
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:26:39 PM

Substantiated

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
01/12/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240112101811

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:	02:46 PM

ALLEGATION(S):

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Staff did not order resident’s medication refills in a timely manner

INVESTIGATION FINDINGS:

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At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA was joined by Licensing Program Manager(LPM) Naira Margaryan and LPA Leizl De La Cerra. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit.

An initial visit was conducted on 01/22/24. Between 11:00 AM to 1:00 PM, LPA conducted an interview with the Administrator, Business Office Manager, Wellness Coordinator, one staff (1), one (1) MedTech, and eight (8) out of nine (9) residents. Additionally, LPA requested copies of pertinent information which include, but not limited to Medication Policy, MAR(medication administration record), Centrally Stored Medication and Destruction Records (CSMDR) for Resident #1 (R1) and R2, R3, and R4, Staff training etc., Moreover, on 02/12/2024, additional interviews with the wellness coordinator, and medical technician were conducted.

Continue on LIC 9099

Substantiated

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)

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Control Number 31-AS-20240112101811

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

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During the investigation, LPA was able to review the medication delivery document, and MAR for Resident # 1 (R1). The CSMDR was partially complete. Upon review it was determined that R1’s medication was not refilled in a timely manner back in 01/02/2024, due to the late submission of the refill request from the facility to the pharmacy. Based on the interviews and record review, R1’s medication ran out on 01/03/2024, and the facility sent the refill request on 01/02/2024. Records review during this visit also confirmed that medication was refilled and delivered to the facility on 01/08/2024.

Additionally, during the review of R1’s (MAR/CSMDR) LPA observed an additional discrepancy. On 01/08/24 R1 was relocated to a different facility, review of MAR indicated that the staff continued to initial R1’s medications as given even after R1 no longer resided at the facility. The MAR was initialed every day until 01/14/24. Wellness Coordinator and Medical Technician were unable to provide an explanation to the LPA as to how this discrepancy occurred. Based on the information and records review obtained this allegation is deemed Substantiated.

Deficiency issued on LIC 9099 D. Exit interview conducted and appeal rights explained. Copy of this report signed and delivered.

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)

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Control Number 31-AS-20240112101811

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/01/2024 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a) A plan for incidental medical care shall be developed by each facility... This requirement is not met as evidenced by	1 2 3 4 5 6 7	The Administrator has agreed to the following: 1. The Administrator shall take state approved vendor training on Incidental Medical and Dental Care. 2. Submit the training certificate to CCL.
	8 9 10 11 12 13 14	Based on interviews and medical records review the facility did not refill medication on timely manner for R1. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/01/2024 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	Conduct inimical- Denial, suspension, or revocation of license; grounds… (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not evidenced by:	1 2 3 4 5 6 7	Formal medications training by a vendor. All staff responsible for assisting with meds including the Administrator. Training shall include the training material, facility medications policy, and staff sign in sheet with the day, training and time spent.
	8 9 10 11 12 13 14	Based on medication record review and interview, the facility staff were marking the MAR days in advance of actually giving the medication, which is conduct inimical. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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