197803785-1-6-2026-28-AS-NMAN-DQ3VRW-20260106154037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803785
Report Date: 01/06/2026
Date Signed: 01/06/2026 03:40:50 PM

Document Has Been Signed on 01/06/2026 03:40 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 HOME		FACILITY NUMBER:	197803785
ADMINISTRATOR/ DIRECTOR:	DELIA COLLANTES		FACILITY TYPE:	735
ADDRESS:	4174 CENTER ST.		TELEPHONE:	(626) 813-7525
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY: 6		CENSUS: 4	DATE:	01/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Delia Collantes, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 Analyst (LPA) Nune Margaryan conducted an unannounced annual visit. LPA met with Administrator, who assisted with the visit. LPA explained the reason for the visit. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with 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. At the time of visit there was one (1) client at the facility. Three (3) clients were at the Day program. The facility is located in a residential area. LPA toured the home and inspected 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 locked 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. Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/06/2026

NARRATIVE

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LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the kitchen and in the laundry area. 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. Medications are documented properly and given as prescribed. LPA reviewed clients and staff files and observed that all clients files are updated and confirmed that staff working have fingerprint clearances. Administrator certificate expired 06/09/2025. Administrator stated she started the required classes online but did not finish and did not complete all the required courses for recertification. The last fire drill was completed 01/03/26.

Deficiency was noted on LIC 809D.

Exit interview was conducted with Delia Collantes and a copy of this report with appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2026 03:40 PM - It Cannot Be Edited

Created By: Nune Margaryan On 01/06/2026 at 03:25 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MELROSE HOME	FACILITY NUMBER: 197803785
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064.3(d)

Administrator Recertification Requirements. To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above. Administrator Certificate expired 6/09/2025, which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated she started the required classes online but did not finish and did not complete all the required courses for recertification. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof of completed courses, as well as proof that training was submitted to the certification unit. If an extension is needed Administrator shall notify LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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