<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803785
Report Date: 01/22/2024
Date Signed: 01/22/2024 01:25:27 PM

Document Has Been Signed on 01/22/2024 01:25 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MELROSE HOMEFACILITY NUMBER:
197803785
ADMINISTRATOR:DELIA COLLANTESFACILITY TYPE:
735
ADDRESS:4174 CENTER ST.TELEPHONE:
(626) 813-7525
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 4DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH: Antonio VergaraTIME COMPLETED:
01:40 PM
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
Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Antonio Vergara who assisted with the visit. Administrator Delia Collantes was notified about the visit. LPA explained the reason for the visit.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center. 1 client was at the Day program at the time of visit. This is a single-story home located in a residential neighborhood and consists of the following: 3 clients bedrooms, 1 staff room, 1 clients bathroom, 1 staff bathroom (inside of staff room which is locked), living/dining room area, kitchen, laundry area, detached garage, backyard, and front yard. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating / patio area for the clients located in the backyard. The detached garage in the backyard and inaccessible to clients. Passageways and exits are free of obstruction. Client bedrooms and bathroom were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathroom is clean and have the required hygiene items. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. Extra linens, blankets, towels, and personal hygiene supplies were observed. Clients personal hygiene supplies are stored in the cabinet located in the dining room. There is a fireplace located in the living room area which covered by a screen. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the kitchen and in the laundry area.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MELROSE HOME
FACILITY NUMBER: 197803785
VISIT DATE: 01/22/2024
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
 Fire extinguisher observed in the kitchen fully charged. Carbon monoxide/smoke detector in the hallway and in the client rooms are operational. The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the dining room. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to Antonio Vergara.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2