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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600808
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:51:14 PM

Document Has Been Signed on 07/14/2025 03:51 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MELROSE CARE HOME IIFACILITY NUMBER:
374600808
ADMINISTRATOR/
DIRECTOR:		LILIA P. RENAFACILITY TYPE:
740
ADDRESS:1627 MARL AVENUETELEPHONE:
(619) 498-0911
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 4DATE:
07/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Lilia RenaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee/Administrator Lilia Rena.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of four (4) residents in care, of whom one (1) was ambulatory and three (3) were non-ambulatory, but none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeters, and none of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for all residents and personnel records for all active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. Where tested, hot water temperature at taps accessible to residents were all compliant: Kitchen Sink was 113 F, Bathroom #1 Sink was 112.5 F, and Bathroom #2 Sink was 114.1 F.

[CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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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Document Has Been Signed on 07/14/2025 03:51 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/14/2025 at 02:57 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MELROSE CARE HOME II
FACILITY NUMBER: 374600808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, licensee did not ensure that the name, address, and telephone number of each resident's dentist was readily aviable to that resident, the licnesee, and facility staff. This posed a potential health risk to 4 of 4 residents (R1 through R4) in care.
POC Due Date: 08/14/2025
Plan of Correction
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Licensee agreed to communicate with the responsible persons for R1 through R4, as needed, to identify the name, address, and telephone number of a preferred dentist for the resident. Licensee agreed to add this information to the LIC601”facesheets” for R1 through R4, and E-mail copies of such to LPA, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MELROSE CARE HOME II
FACILITY NUMBER: 374600808
VISIT DATE: 07/14/2025
NARRATIVE
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[CONTINUED FROM LIC 809] Appliances to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher had been professionally inspected within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff were trained on PPE within the last twelve (12) months. Licensee presented proof of current business liability insurance.

During facility tour, LPA observed, and manager interview confirmed: The facility’s manual fire alarm pull station and bell alarm had not been inspected/serviced within the last twelve (12) months. Two (2) of six (6) smoke detectors were initally non-working. [During today's visit, Licensee inserted fresh batteries into both smoke detectors, correcting the problem.] These items were necessary to maintain ongoing compliance with the facility’s prior approved Fire Clearance. During records review, LPA observed, and manager interview confirmed: Licensee did not record the name, address, and telephone number of a primary dentist for 4 of 4 clients [Client #1 (C1) through Client #4 (C4)], as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.]

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding a videoconferencing device dedicated for resident use (refer to the LIC9102-TV page), and Technical Assistance (TA) regarding staff alert devices on exit doors and refresher training on Mandated Reporting requirements for staff (refer to the LIC9102-TA pages).

An exit interview was conducted with Licensee/Administrator Lilia Rena, to whom a copy of this report, the LIC 809-D page, the LIC9102-TV page, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/14/2025 04:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/14/2025 04:07 PM


Created By: Dang Nguyen On 07/14/2025 at 03:19 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MELROSE CARE HOME II
FACILITY NUMBER: 374600808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety: “All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain the facility in continuous conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire. This posed an immediate safety risk to 4 of 4 residents (R1 through R4) in care.
POC Due Date: 07/14/2025
Plan of Correction
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During today’s visit, Licensee remedied the two (2) non-working smoke alarms and phoned a professional fire safety inspector/vendor to make an appointment for servicing of the facility’s manual fire alarm pull station and bell alarm. These actions resolve the immediate risk. Licensee agreed to send LPA proof of completion in the form of a paid invoice and/or updated service tag as soon as work is completed, but no later than 08/14/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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