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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610370
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:44:46 PM

Document Has Been Signed on 10/22/2024 02:44 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:
10/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Nancy AdamsTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Today, Tuesday, 10/22/24, at 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a continuation of the required annual facility Inspection initiated on Monday,10/21/2024. LPA met with Administrator Designee, Nancy Adams, and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested and works properly. Fire extinguishers were observed throughout the facility on all floors; last serviced on December 24, 2023. Evacuation chair was observed atop the second floor stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Fire drill last conducted September 25, 2024.

Medications: Medication room is located on second floor. LPA observed room as secured and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room.

Laundry: LPA observed the laundry rooms located on the first and second floor. Laundry area is clean. Detergents, cleaning supplies, and other toxins, are securely stored and inaccessible to residents.

Commons: Activity rooms, dining area, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

[Continued on LIC 809-C]

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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: 10/22/2024
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Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms were inspected and observed to maintain required furnishings and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction.

Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 111°F., within the required range.

Outdoor (courtyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

Resident records: A total of six (6) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.



Staff records: A total of six (6) Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility representative, Administrator Designee, Nancy Adams.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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