Melrose Gardens

Allegation investigated: Staff neglected to provide proper care and supervision to resident resulting in injury- Resident’s pressure wound worsened due to staff neglect- Staff were distracted by their personal phones and not meeting the needs of residents-

This is an addendum the the previous report issued on 5/23/2025. On 3/27/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived at the facility to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 05/22/25, at which time LPA spoke with the facility Administrator, Staff, and Witnesses having knowledge of the above noted allegations. In addition, between 12:10 pm and 1:30 pm, LPA received facility resident and staff roster, Resident #1 (R1’s) facility records, included but not limited to, physician report, assessment, need and service plan, functional capability assessment, hospital discharge records and other pertinent documents. Between 1:35 pm and 2:15 pm, LPA interviewed facility staff and R1’s responsible family member. During subsequent visits, LPA discussed R1’s overall health conditions to clarify what kind of services R1 was receiving from staff and 3rd party home health care providers. On 09/19/2025, during subsequent visit between 10:15 am and 12:30 pm, LPA Comer requested and reviewed Resident #2 (R2s) records, interviewed Staff, and five (05) out of a total of thirty-one (31) residents. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff neglected to provide proper care and supervision to residents,resulting in injury. It was alleged that on 5/11/25 at 1:00 PM in the dining area, R1 was observed with bruising around their eyes. R1 was questioned by the their responsible family member (F1) and R1 stated that the facility is awful, that someone probably punched R1, but refused to provide additional details. Staff revealed that they provide wellness checks to R1 a minimum of every two hours. R1 is under staff observation in the common areas and is being assessed and supervised as frequently as necessary. Staff explained that on 05/05/2025 during lunch time R1 got too close to the Resident#2 (R2), and accidentally touched R2. By the time staff went to redirect R1, R2 grabbed the plate from the table and threw it at R1; Staff immediately separated R1 and R2. Staff revealed that R1 had a health condition triggering behaviors that could disturb other residents. Therefore, they were always monitoring R1. Staff stated that R1 did not have fall incidents that could cause bruise around their eyes. LPA was unable to communicate with R1 due to R1’s inability to respond to questions. Other residents interviewed during investigation did not address any concerns regarding the assistance provided by facility staff. A review of facility records verified the information received from staff. Based on the information obtained through observation, records review, and interviews, it was concluded that although R1 may have been involved in the incident, causing injuries, there is not sufficient information to conclude that staff neglected to provide required care and supervision to R1. Hence, the allegation is UNSUBSTANTIATED at this time. Allegation: Resident’s pressure wound worsened due to staff neglect- Concerns were addressed that a prior bed soar, above R1’s buttock had worsened and appeared to be 6 inches long by 3 inches wide. Four months ago, the wound was much smaller. Staff revealed that R1 had a wound on their buttock and was receiving home health care services for wound care. As per Staff’ observation, and the information received from home health nurses, the wound was healing. A review of R1’s home health care records verified that R1 wound was responding to treatment and healing. During investigation, LPA Comer was able to observe R1’s wound, finding the skin to be dry and wound healing well. [LIC 9099C] Continued- Based on interviews, observation, and record review, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff were distracted by their personal phones and not meeting the needs of residents- Complainant alleges that staff neglected to assist R1 with toileting assistance as they [staff] were instead distracted using their cell phones during working hours. During initial and subsequent visits, LPA conducted multiple tours of the facility in the morning and afternoon shifts and observed the following: Staff were witnessed providing consistent care and assistance to residents; no residents were witnessed by LPA as neglected by staff. During LPA interviews with Administrator and staff, they refuted this allegation, stating that staff provide assistance to residents in care on a consistent basis. Staff stated that if they need to make a phone call while working their shift, they will ask co-staff to provide temporary coverage until they return to their work duties. Residents’ interviews revealed that staff provide resident care and supervision on a consistent basis and that resident assistance was not neglected due to staff's personal issues. Based on the information LPA obtained through observation, and interviews with staff and residents, It cannot be proven that staff neglect to meet residents needs, nor are distracted by personal matters. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 31-AS-20250516141919

Type of visit: Required - 1 Year

On 09/30/25, 8:30 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Yossi "Joseph" Wieder, and reason for the visit was disclosed. Facility is licensed as a single-story building. Fire clearance approved for thirty-one (31) non-ambulatory residents. Bedridden cleared for thirty-one residents. Hospice waiver approved for thirty-one (31). Currently, there are two (2) residents receiving hospice care services; none bedridden. At 10:15 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. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F; within the required range. Facility maintains an approved Mitigation and Infection Control Plan. Required postings are displayed and observed to be current. Disaster drills last conducted on September,2025 Commons: Activity room and dining room observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. [LIC 809C]-continued 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 worked properly. Two (2) fire extinguishers are located at opposite ends of the facility; extinguishers last serviced on December 24, 2024. Evacuation routes are clearly labelled and posted. Kitchen: At 11:15 am, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food which was properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near food areas. Medications: Medication room is located next to the facility entrance; LPA observed room as locked and inaccessible to residents. Medications are properly labeled and stored in secured medication carts. 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 room, located in outdoor storage compartment. Laundry room, detergents, cleaning supplies, and other toxins, are secured and inaccessible to residents. Bedrooms: At 11:50 am, LPA observed resident bedrooms and bathrooms for safety, privacy, and comfort. Random bedrooms (#109, #110, #113, #118) were inspected and observed to maintain required furnishings, sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear of 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 114.0°F. Within the required range. Outdoor (rear courtyard) area observed to have a shaded patio, with table and sufficient seating for 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. [LIC 809C]-continued Resident records: Records are stored in locked cabinets within the Administrator's office and inaccessible to residents. A total of four (4) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, admission agreements, and all relevant documentation. Resident records appeared to be complete and current. Staff records: Records are stored in locked cabinets within the Administrator's office and inaccessible to residents. A total of six (6) Staff files were reviewed. Criminal record clearances, Health Screening, CPR/First Aid, and all relevant documentation were review by LPA. Staff records appear 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 provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Facility staff are not properly safeguarding medications-

At 8:45 am, Friday, 5/23/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 05/14/25. LPA met with facility Administrator, Marco Villegas, presented official CDSS badge identification, and reason for the visit was disclosed. At 9:05 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation(s), LPA received Facility resident roster, and staff roster. LPA interviewed the Administrator, staff, and residents. [LIC 9099C]- Continued Substantiated Allegation: Facility staff are not properly safeguarding medications - The Reporting Party (RP) alleges that a staff member left their child in the medications room unattended during their scheduled work shift. LPA conducted an interview with the Administrator, which revealed the following: Per the Administrator, he allowed the staff member (S1) in question to let their child sit in the medications room. "It was a Sunday, and S1 did not have anyone to watch over the child that day. He [the child] was sitting in S1's vehicle and it was a very hot day, so I allowed S1 to bring her child in the medications room." Per the Administrator, "All medications are securely locked in medication carts and overhead cabinets, so there was no way for unauthorized persons to access any medications." LPA conducted an observation of the medications room which revealed the following: Door to medications room was locked and inaccessible to residents. Inside the room, all medications were witnessed as securely locked in medication carts and overhead cabinets. However, the Administrator admits that non-authorized persons were allowed access in the medications room. Based on the information LPA obtained through observation, interviews with the Administrator, staff, residents, the allegation that facility's medications were not properly safeguarded is Substantiated. Deficiency is cited on the LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, May 23, 2025 · control 31-AS-20250505152734

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 23, 2025

87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA interviews with the Administrator and Staff, the licensee failed to ensure that the facility's medication room was inaccessible to persons other than athorized personnel which posed an immediate health risk to residents in carethe state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: All staff will complete in-service training regarding access policy to medications room within ten days of this citation. Licensee will provide statement that moving forward, medication room access policy will comply with regulations. Evidence of completion to be submitted to LPA as POC.

Type of visit: Case Management - Deficiencies

On 05/23/25 Licensing Program Analyst (LPA) Raymond Comer, conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. This case management visit was conducted in conjunction with complaint investigation #31-AS-20250516141919 to address deficiencies related to the complaint. During the initial complaint investigation, LPA conducted a facility records review and interviews with Administrator and Staff which revealed the following: On 5/05/25, an incident occurred in which Resident#2 (R2) committed an aggressive act upon Resident#1 (R1). Staff contacted the Primary Care Physician for both R1, and R2. Additionally, staff informed responsible family members of R1, and R2 concerning the incident. However, staff did not report to issue to the the Administrator, and as a result, the facility did not submit an incident reports or other required reports to the Licensing Division. At the time of this visit, the Administrator was informed that staff are not following reporting requirements and failed to follow Tittle 22 reporting requirements. Deficiencies are cited on the corresponding 809-D page. No immediate health or safety hazards were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, May 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 23, 2025

87211(a)(1) Reporting Requirements- A written report shall be submitted to the licensing agency...and person responsible for the resident within seven days of the occurrence of any of the events specified...This requirement is not met as evidenced by: Based on LPA records review and interviews with Administrator and Staff, Licensee failed to submit an Incident Report to licensing agency within seven days of the incident's occurance, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Licensee has agreed to conduct an in-service training for all staff about the section cited. Licensee shall submit proof of training by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(c) · Plan of correction due date: May 23, 2025

87211(c) Reporting Requirements-Any suspected physical abuse that does not result in serious bodily injury...shall be reported to local ombudsman...and local law enforcement agency within twenty-four (24) hours...This requirment was not met as evidenced by: Based on LPA records review and interviews with Administrator and Staff, Licensee failed to report to ombudsman and local authorities as required, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: The licensee has agreed to conduct an in-service training for all staff about the section cited. The licensee will submit proof of training by the POC due date.

Type of visit: Required - 1 Year

On 12/12/24, 9:45 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Marcos Villegas, and reason for the visit was disclosed. Facility is licensed as a single-story building. Fire clearance approved for thirty-one (31) non-ambulatory residents. Bedridden cleared in thirty-one residents. Hospice waiver approved for thirty-one (31). Currently, there are two (2) residents receiving hospice care services; no bedridden at time of visit. At 10:15 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. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 75.0°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 on September 25, 2024 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. Two (2) fire extinguishers were observed on opposite ends of the hallway; extinguishers last serviced on December 24, 2023. Evacuation routes are clearly labelled and posted throughout the facility. Fire drill last conducted September 25, 2024. [LIC 809-C] Continued- Kitchen: At 10:45 am, 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 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. Medications: Medication room is located next to the facility entrance; LPA observed room as locked and inaccessible to residents. Medications are properly labeled, and stored in secured medication carts. Medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room. Laundry: At 11:12 am, LPA observed the laundry room, located in outdoor storage compartment. Laundry room, detergents, cleaning supplies, and other toxins, are secured in locked compartment area and inaccessible to residents. Laundry area is clean and clear from obstruction. Commons: Activity room, and dining room, observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: At 11:35 am, LPA observed random resident bedrooms and bathrooms for safety, privacy, and comfort. Resident rooms were inspected and observed to maintain required furnishing 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 113.5°F; Within the required range. Outdoor (rear 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: At 12:15 pm, LPA observed records room, located in Administrator's office, as secured and inaccessible to residents. A total of three (3) 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. [Continued on LIC 809-C] Staff records: At 12:40 pm, LPA observed records room, located in Administrator's office, as secured and inaccessible to residents. A total of three (3) 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 the Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024