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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610370
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:46:39 PM

Document Has Been Signed on 10/21/2024 12:46 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELROSE GARDENSFACILITY NUMBER:
197610370
ADMINISTRATOR/
DIRECTOR:		VILLEGAS, MARCOFACILITY TYPE:
740
ADDRESS:960 N. MARTEL AVENUETELEPHONE:
(323) 876-1746
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 100CENSUS: 57DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Nancy AdamsTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 10/21/24, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Administrator Designee; Wellness Director, Nancy Adams, and reason for the visit was disclosed.

Facility is licensed as a two story building. Fire clearance approved for seventy-two (72) non-ambulatory, and twenty-eight (28) ambulatory, for total capacity of one hundred (100) residents. Bedridden cleared for bedrooms #101-#107, #109, #111, #113, #115, #117, #119, #120, and #122. Hospice waiver approved for twenty (20). Currently, five (5) residents receiving hospice care services and no bedridden.

At 10:30 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility.

Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 77.0°F. within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted: September 25, 2024.

[LIC 809C] Continued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2024
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Kitchen: At 11:15AM, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are secured, and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas.

Resident records: A total of six (6) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current.



Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date.

Exit interview conducted/Copy of report given to Administrator Designee, Nancy Adams.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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