Melrose 30

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Caregiver Mayen Ladrillono. According to the facility’s license, the facility serves residents age 60 and over and has a maximum capacity of 6 residents. All residents may be non-ambulatory, and there is a hospice waiver granted for 6. LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. 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 in working order. Extra linens and hygiene supplies were present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (CONTINUED ON LIC 809C) (CONTINUED FROM LIC 809) No pools or bodies of water were observed on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records. Resident records reviewed did not contain the required documentation. Confidential records were stored in locked areas. Proof of current/active business liability insurance was presented. One deficiency is being cited during today's visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A plan of correction was jointly developed with Administrator Justin Mendoza. An exit interview was conducted with Administrator Justin Mendoza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to open a complaint investigation and conduct a Health and Safety Check (H&S). LPA met with Administrator Mendoza, to whom LPA disclosed the reason for the visit. During the visit, it was determined Resident1 (R1) did not reside at the facility, therefore the complaint was determined unfounded and dismissed. An exit interview was conducted with Administrator Mendoza, and copies of this report and Licensee Rights (LIC 9058 01/16) were provided at the conclusion of the visit. Signature on this form acknowledges receipt of these rights and a copy of this report. Unfoundedthe state’s words, verbatim · CDSS document, Mar 19, 2026 · control 08-AS-20260312151621

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census: 5 COMP II Participants: Melanie Tena, Managing Member, Justin Mendoza, Administrator Interview Method: Telephone interview On 1/30/26, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Amy Rodgers conducted an announced Pre-licensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 1/24/2025. The facility was approved to care for six (6) Elderly Residents; of which six (6) are Non-Ambulatory.LPA was greeted by, identified herself to, and explained the purpose of the visit to the applicant’s representative, Justin Mendoza. Structure- The facility is a single story structure with 6 bedrooms and 5 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed. Bedrooms Residents- Rooms #1, #2, #3, #4, #5 & #6 for Non-Ambulatory use. Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats. Linens & Hygiene Supplies- Adequate supply in the hall storage closet.. Emergency Phone Numbers, Exit Plan and Required Postings- Posted. Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired. Appliances- Stove burners, oven, microwave, washer, and dryer working. Toxins- Stored and locked under the sink in cabinet. Water Temperature- Measured compliant in the all facets accessible to clients: bathrooms and kitchen. Medications- Centrally stored and locked in a cabinet in the kitchen.. First-Aid Kit- Stored in a locked cabinet in the kitchen Resident & Staff Files- Stored in a locked cabinet in the kitchen. Activities- Adequate supplies to include exercising, and games for resident's use are stored on campus. Fire clearance- Approved on 1/24/25. Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance. All items reviewed during the visit are in compliance. Pre-licensing is complete and this facility has no deficiencies. Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Justin Mendoza Administrator signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 14, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Amy Rodgers conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to the applicant’s representative, Justin Mendoza, Administrator. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. There are items which must be corrected for the facility to comply with regulations. The applicant did not pass the pre-licensing inspection, and a return visit will be required. An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Amy Rodgers conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to the applicant’s representative, Justin Mendoza, Administrator. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. There are items which must be corrected for the facility to comply with regulations. The applicant did not pass the pre-licensing inspection, and a return visit will be required. An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 7, 2025