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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609076
Report Date: 05/06/2021
Date Signed: 05/06/2021 03:16:40 PM

Document Has Been Signed on 05/06/2021 03:16 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE VILLASFACILITY NUMBER:
197609076
ADMINISTRATOR:VERGARA, KANDICEFACILITY TYPE:
740
ADDRESS:823 N POINSETTIA PLACETELEPHONE:
(323) 746-7840
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 68CENSUS: 48DATE:
05/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Alexcis Peralta-assitant administratorTIME COMPLETED:
11:30 AM
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This Case Management visit was conducted in conjunction with complaint investigation to address the issues unrelated to the complaint.
  • Upon entry to the facility, Licensing Program Analysts (LPAs) Naira Margaryan and Rosaura Valenzuala observed that front desk was left unattended for extended period of time.
  • The residents were walking in the hallways, coming in and out of the elevator communication with each other without masks.
  • One of the residents on wheelchair keep coming towards LPAs without mask and there were no staff to redirect the resident and to remind them to wear the mask.
  • LPA were waiting at the front desk for over 15 min and no one came to check LPAs temperature and provide the visitation log and COVID-19 questioner to the LPAs.
Assistant Administrator arrived around 9:20am and assisted LPAs to the dining room to provide workstation.
  • LPAs observed that the tables in the kitchen were not cleaned and sanitized after being used for breakfast.

All noted issues were discussed with the assistant administrator and she was informed that under Title 22, Division 6; Chapter 8 following citations were issued and recorded on LIC809D
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Naira Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2021
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 3
Document Has Been Signed on 05/06/2021 03:16 PM - It Cannot Be Edited


Created By: Naira Margaryan On 05/06/2021 at 10:00 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2021
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, additional staff shall be employed as necessary for the provision of adequate services. This requirement is
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The Administrator will provide written documentation explaining how they are going to ensure that the reception desk is not left unattended. The copy of schedule identifying the staff working at the reception desk will be provided to the LPA by POC due date.
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not met as evidenced by; Licensee did not ensure that the facility has designated receptionist at the front desk to provide required assistance. The front desk was left unattended for extended period of time and it was not clear if staff was scheduled to work at reception desk. This poses a potential health and safety risk to residents in care.
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Type B
05/14/2021
Section Cited
CCR87212(a)

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87212 Emergency Disaster Plan; (a) Each facility shall have a disaster and mass casualty plan of action. This requirement is not met as evidenced by;
The staff did not follow the COVID-19 Policies and procedures identified in the emergency disaster plan. This poses a potential health and safety risk to residents in care
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The Administrator will provide written plan of action explaining how they need to ensure that the Emergency disaster plan related to COVID 19 is being followed.

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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
LICENSING EVALUATOR NAME:Naira Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/06/2021 03:16 PM - It Cannot Be Edited


Created By: Naira Margaryan On 05/06/2021 at 10:48 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MELROSE VILLAS
FACILITY NUMBER: 197609076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by
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The Administrator will provide additional training to kitchen staff to explain the cleaning protocol and COVID 19 policies and procedures. Written document will be provided explaining the topics of the training and sign in sheet.
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The Licensee did not ensure that the facility is clean and sanitary. The dining room tables and floor were not cleaned and sanitized after the residents finished their breakfast.
This poses a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Naira Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2021


LIC809 (FAS) - (06/04)
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