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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609076
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:31:32 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
06/13/2025 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20250613093622
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:
06/20/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lori McKayTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not ensuring that the facility is free of pests-
INVESTIGATION FINDINGS:
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Today, Friday, 6/20/25, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation(s). LPA met with Administrator, Lori McKayl, presented official CDSS badge identification, and reason for the visit was disclosed.

At 8:15 am, LPA conducted a physical plant tour; no health and safety issues were observed.

To investigate this allegation, LPA received facility resident roster, and staff roster. From 8:30 am to 10:00 am, LPA reviewed Resident#1's file. From 10:20 am to 11:05 am, LPA conducted a tour of facility common areas, and random inspection of resident bedroom. From 11:15 am, to 2:30pm, LPA interviewed residents and staff.

[LIC9099C]-Continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20250613093622
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 VILLAS
FACILITY NUMBER: 197609076
VISIT DATE: 06/20/2025
NARRATIVE
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Allegation: Staff are not ensuring that the facility is free of pests - Reporting Party (RP) alleges that facility is experiencing pest control issues, stating that Resident#1 (R1) has seen cockroaches in the television/activities room. Additionally, the RP alleges that R1's bedroom has bed bugs and that the facility does not contract with a professional pest control service vendor.
LPA interviews with staff revealed the following: The Administrator and Staff#1 (S1) confirm that the facility is contracted with pest control service vendor, Ecolab, who is currently providing eradication treatments, facility wide, to eliminate stated pest issues. Per staff, R1's room is scheduled for pest control treatment.
LPA interviews with residents revealed the following: Out of a total of forty-six (46) residents, three (3) out of six (6) residents state observing cockroaches in facility common areas.

Based on the information gathered during this visit, LPA determined that there was sufficient evidence to confirm the allegation of bedbugs and cockroach pest issues present in the facility. The allegation is substantiated. Deficiency cited on LIC9099-D Citation issued for CCR 87303(a) Maintenance and Operation on complaint control # 31-AS-20250326163124 and complaint control# 31-AS-20250409171120.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250613093622
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 VILLAS
FACILITY NUMBER: 197609076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
80087(a)(1)
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80087(a)(1) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times…(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:
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Administrator has agreed to work with facility's pest control vendor to create a proposal for the enhanced treatment and eradication of pests in the facility. Administrator will submit a proposa to LPA by 7/5/25.
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Based on interviews, staff failed to ensure that the facility is free from insects and pests, this poses a potential health and safety and personal rights risk to persons 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3