Melrose Gardens

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure the safety of residents from other residents.

On Friday, 03/27/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with the Administrator, and reason for the visit was disclosed. At 9:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. During LPA's tour of the facility, LPA observed California RCFE Complaint Poster (PUB 475) prominently displayed in common area of the facility. To investigate the allegation, Between 10:05 am and 10:35 am, LPA received and reviewed Facility Resident roster, Personnel roster, Resident#1 (R1) Physician Report, Appraisal/Needs & Services Plan, and other pertinent documentation. Between 11:00 am, and 12:30 pm, LPA interviewed the Administrator, Three (3) Staff, and Six (6) Residents. [LIC9099C] Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 31-AS-20260323090813

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not safeguard resident's personal belongings. Staff do not allow resident to have visitors.

On Thurday, 1/15/26, Licensing Program Analyst (LPA) Raymon Comer conducted an unannounced subsequent visit to the facility to conduct additional investigations and render findings for the above noted allegations. LPA met with the Administrator, and informed them about the purpose of this visit. The investigation of the allegations was initiated on 11/04/2024 at which time LPA Comer requested residents and staff rosters. At 11:30 am, LPA requested and received copies of Residents files, including but not limited to Physician report, need and service plan, inventory records of resident(s) personal belongings and other documents relevant to investigation. In addition, on 12/04/2025, between 12:10 pm and 12:30 pm, LPA inspected R1’s room and observed and assessed R1. At 12:45pm, other residents and staff were interviewed. [LIC9099C] Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 31-AS-20241029123550

Allegation investigated: Staff withheld medication from a resident in care.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. ---Staff failed to ensure proper medication administration. It was alleged that Staff #1 (S1) withheld Resident #1's (R1) insulin at 4:30p.m on 12/29/2025. when requested. To investigate the allegation, on 12/29/2025 at around 10:00a.m, LPA requested documents and interviewed three (03) staff and six (06) residents 10:30a.m. to 12:00p.m. A review of physician's orders states R1 is to take insulin at 8:00a.m., 12:00p.m. and 4:00p.m. A review of facility staff records shows R1 received all medications as prescibed on the date of the alleged incident. A review of the facility staff schedule shows S1 was not working on the date of the alleged incident. During interviews with staff, all staff stated they do not refuse resident medications and R1 was given their medications as prescribed. (CONT. on LIC909the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 31-AS-20251223092143

Allegation investigated: Staff does not ensure resident receives adequate food service. Facility is not kept clean and sanitary. Staff do not ensure that resident has clean linen.

At 10:05 am, Thursday, 12/04/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent complaint investigation regarding the allegation(s) listed above. Inital 10-day visit conducted on 11/04/24. LPA met with Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:20 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. Between10:40 am and 11:25 am, LPA reviewed Resident 1's (R1) file, and documents relevant to the investigation. Between 12:10 pm and 1:45 pm, LPA observed R1, their bedroom, interviewed staff and residents. [LIC 9099C]-Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 31-AS-20241029123550

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff failed to ensure proper medication administration. Staff violated resident rights to privacy and property security.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. ---Staff failed to ensure proper medication administration. It was alleged that staff are leaving Resident #1’s (R1) medications in their rooms in a cup and then walking away without ensuring R1 took their medications once dispensed. To investigate the allegation, on 08/15/2025 at around 10:30a.m. LPA conducted a physical plant tour and requested documents. LPA also interviewed four (04) staff from 11:30a.m. to 2:00p.m. On 10/21/2025, LPA interviewed six (06) residents from around 11:30a.m. to 1:00p.m. A review of facility staff records shows that all MedTechs have completed all required training. (CONT. on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 4, 2025 · control 31-AS-20250812142625

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff failed to provide adequate food service and meal accommodation. Licensee failed to ensure staff can communicate with residents in care.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Joseph Weider and explained the reason for the visit. --- Staff failed to provide adequate food service and meal accommodation. --- Licensee failed to ensure staff can communicate with residents in care. It was alleged that the food is inedible, that facility does not offer alternatives and kitchen staff don't speak any English, finding difficult to communicate their needs. To investigate the allegation, on 08/15/2025 at around 10:30a.m. LPA conducted a physical plant tour, and requested documents. LPA also interviewed four (04) staff from 11:30a.m. to 2:00p.m. On 10/21/2025, LPA interviewed six (06) residents from around 11:30a.m. to 1:00p.m. During the physical plant tour, LPA observed a variety of well-balanced foods being offered and served. (CONT. on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2025 · control 31-AS-20250812142625

Allegation investigated: Staff do not prevent resident from entering other residents rooms-

At 10:00 am, Thursday, 5/01/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 12/12/24. LPA met with facility Administrator, Marco Villegas, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. LPA conducted a review of Resident 1's (R1) file, and documents relevant to the investigation. Between 11:15 am and 1:30 pm, LPA interviewed the Executive Director, Residents and Staff. [LIC 9099C]- Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, May 1, 2025 · control 31-AS-20241206091537

Allegation investigated: Staff do not answer the facility telephone-

On Friday, 03/21/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with Executive Director, Marco Villegas, and reason for the visit was disclosed. At 9:35 am, LPA conducted a physical plant tour; no health and safety issues were observed. During LPA's tour of the facility, LPA observed the telephone to be in working condition. LPA also contacted that facility out of view; the ringtone was present, and and Staff #1 (S1) answered the phone. Additionally, LPA witnessed consistant front desk coverage by staff. To investigate the allegation(s), LPA received Facility Resident roster, and Staff roster. Between 10:00 am, and 1:30pm, LPA interviewed the Executive Director, Staff, and Residents. [LIC 9099C]- Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 21, 2025 · control 31-AS-20250311153509

Allegation investigated: Staff did not distribute residents' medications as prescribed- Staff did not safeguard residents' personal belongings-

On Thursday, 11/14/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial 10-day complaint visit at the facility to investigate the above allegation(s). LPA met with Executive Director, Marco Villegas, and the reason for the visit was disclosed. At 10:15 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. At 10:30 am, LPA conducted a review of Resident files. Between 11:15 am and 12:35 pm, LPA interviewed the Executive Director, Staff, and Conservator. At 1:00 pm, LPA conducted an observation and review of MAR documents in the facility medication room. Between 1:20 pm and 2:00 pm, LPA interviewed Residents. [LIC 9099C]- Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 31-AS-20241104095811

Allegation investigated: Facility staff do not provide adequate incontinent care- Staff do not ensure resident's hygiene needs are being met-

On Monday, 11/04/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced/initial 10-day complaint visit at the facility to investigate the above allegation(s). LPA met with Executive Director, Marco Villegas, and the reason for the visit was disclosed. At 08:35 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. At 9:05 am, LPA conducted a review of Resident 1's (R1) file, and documents relevant to the investigation. Between 9:40 am and 11:45 am, LPA interviewed the Executive Director, and R1's Responsible Family Member (F1), via cellphone. At 12:10 pm, LPA made multiple attemps, via cellphone, to contact the Reporting Party. (RP) However, the RP did not respond. [LIC 9099C]- Continued Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 4, 2024 · control 31-AS-20241029123550

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure facility serves food of good quality and quantity to residents Staff does not ensure residents are spoken to in an appropriate manner Staff do not ensure medications are properly managed for residents

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Marco Villegas and explained the reason for the visit. LPA conducted physical plant tour at 9:33 AM, requested copies of facility documents relevant to the investigation at 10:05 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. Regarding the allegation that Staff does not ensure facility serves food of good quality and quantity to residents, it was alleged that the food quality is not very good, quantity of food portions is also very small and the facility runs out of food. LPA's observation during today's visit at about 10:30 AM revealed that the facility has more than enough stock of food in their walk in refrigerator including but not limited to eggs, milk, vegetables and lots of meat. LPA's interview with kitchen staff today at 11:30 AM revealed that they have food deliveries evthe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 31-AS-20240507132704

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not allow resident to have visitors

This is an amendment of the original complaint report (LIC 9099) issued on 04/30/24. Report was amended to correct verbiage and maintain the confidentiality of Complaintant. Licensing Program Analysts (LPAs), Raymond Comer and Micheal Cava, conducted Health and Safety Inspection of the Facility at 1:20 PM; no issues observed. LPAs spoke with Wellness Director. (S1) They state the Facility does not prohibit residents visitation rights. LPAs spoke with the Reporting Party (RP) who says the Facility Administrator, Marco Villegas, specifically is prohibiting Resident #1's (R-1) family member from visiting at the facility. Additional information obtained from the RP during the investigation indicates that the family member in question lives in a different Adult Care Facility (West Los Angeles VA Home for Heroes) and the medical team at that Facility is temporarily not allowing them to leave their campus at this time. LPAs conducted an interview with Staff at West Los Angeles VA Home for Herthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 31-AS-20240425102904

Allegation investigated: Staff did not order resident’s medication refills in a timely manner

At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA was joined by Licensing Program Manager(LPM) Naira Margaryan and LPA Leizl De La Cerra. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit. An initial visit was conducted on 01/22/24. Between 11:00 AM to 1:00 PM, LPA conducted an interview with the Administrator, Business Office Manager, Wellness Coordinator, one staff (1), one (1) MedTech, and eight (8) out of nine (9) residents. Additionally, LPA requested copies of pertinent information which include, but not limited to Medication Policy, MAR(medication administration record), Centrally Stored Medication and Destruction Records (CSMDR) for Resident #1 (R1) and R2, R3, and R4, Staff training etc., Moreover, on 02/12/2024, additional interviews with the wellness coordinator, and medical technician were conducted. Continue on LIC 9099 Substantiatedthe state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20240112101811

Allegation investigated: Staff did not prevent resident from handling another resident in a rough manner Staff did not prevent resident from making threatening comments towards another resident Staff are not providing a comfortable environment for resident

At 10:45 AM, Licensing Program Analysts (LPAs) Huma Rahimi, DeLaCerra, Leizl, and LPM Naira Margaryan conducted an unannounced initial complaint visit. Team met with the Marco Villegas, Administrator and disclosed the reason for the visit. During course of the investigation, at 10:50 am, LPAs requested resident and staff roster. At 10:55 am, LPAs requested and reviwed copies of pertinent records which include, but not limited to Admission Agreement, Identification Emergency Sheet, Physician Report, Pre-placement Appraisal, Subsequent Appraisal, Incident Report, and Facility Notes, relevant to the investigation. At approximately 11:30 am, LPA conducted a physical plant tour. Between 12:00 PM – 1:00pm, LPA conducted an interview with the Administrator, four (04) staff; two (2) caregivers and two (2) med techs and seven (7) residents. Continue on LIC 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20240221085535

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.