331880993-7-13-2022-18-AS-TDAN-CGB7KB-20220713214341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880993
Report Date: 12/11/2020
Date Signed: 07/13/2022 09:43:53 PM

Document Has Been Signed on 07/13/2022 09:43 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MISSION LAKE VILLA, INC.		FACILITY NUMBER:	331880993
ADMINISTRATOR:	MESROPYAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	65045 BLUE SKY CIRCLE		TELEPHONE:	(818) 807-1338
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY: 6		CENSUS:	DATE:	12/11/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Anahit Mesropyan,		TIME COMPLETED:	02:01 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tricia Danielson contacted the facility via telephone for purpose of conducting a pre-licensing evaluation. At approximately 1:00 PM, LPA met with facility by Administrator (AD) Anahit Mesropyan via Facetime. An initial application to operate a Residential Care For the Elderly facility (RCFE) was submitted to the Central Applications Unit (CAU) on 07/06/20 for a total capacity of six (6) non- ambulatory residents. On 8/31/2020, a Riverside County Fire Department fire clearance was granted for five (5) non-ambulatory residents and one (1) bedridden resident. Component III completed with AD Mesropyan on this date. LPA Danielson observed the following: Structure: Facility was a one story house with four (4) resident bedrooms, one (1) live in caregiver bedroom, two (2) bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the dining area/hallway to control entire house. Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. Bedrooms #3 or #4 will accommodate a bedridden resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. There was one caregiver bedroom for live in staff. Bathrooms: Both resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. At 1:35 PM, LPA observed AD test water temperatures in both resident bathrooms. LPA verified via Facetime that water temperature measured 108.0 degrees Fahrenheit. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MISSION LAKE VILLA, INC.	FACILITY NUMBER: 331880993
	VISIT DATE: 12/11/2020

NARRATIVE

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(CONTINUED FROM LIC 809C)
evidenced by staff's ring from their cellphone.

Pre-Licensing is incomplete with deficiencies to be resolved as soon as possible. A follow up pre-licensure LIC809 will be generated upon resolution of deficiencies.

The following items need to be corrected before the facility can become licensed:
The posting of the Let-Us-Know and Ombudsman posters.
Side gate much have be self latching when released.

Applicant will notify LPA of completion of the above items. The license will be granted based on final review by and approval from the Central Applications Unit.

SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MISSION LAKE VILLA, INC.	FACILITY NUMBER: 331880993
	VISIT DATE: 12/11/2020

NARRATIVE

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(CONTINUED FROM LIC 809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. Via Facetime, LPA observed the freezer temp at 0 degrees Fahrenheit and the refrigerator at 40 degrees Fahrenheit. LPA observed the stove to be operational. There was adequate seating for meals for all residents. Sample menu was posted on the refrigerator. LPA observed the required 72 hour emergency food supply to be stored in a kitchen pantry. Laundry area with washer and dryer were located in the garage.
Living/Family room:
There were two separate living/family areas with safe and adequate seating for all residents as well as working TV.
Yards/Outside:
There was a patio with adequate umbrella covered seating for all residents. Fencing secured the entire backyard. To the right of the front yard a metal gate lead to the backyard. LPA observed that the gate did not self latch when released. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
There was a washer and dryer located in the garage. Laundry detergents and cleaning solutions were secured and inaccessible to residents. LPA observed a 72 hour emergency supply water was also located in the garage. Garage was organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan:
An activity calendar, AD certificate, Emergency Disaster Plan were posted in the entry way. Facility exit plan was posted near the front door. The required Let-Us-No poster and Ombudsman poster were noted to be missing from the facility.
General items:
Fire extinguisher was charged and mounted in the kitchen and entry way. Seven (7)moke/carbon monoxide alarms were tested and were in working order. Flashlights for use in the event of an emergency were located in each resident room and as well as the hallway. Flashlights were tested and found to be operational. Resident records will be stored in a locked filing cabinet near the kitchen. First Aid kit and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as
(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020

LIC809 (FAS) - (06/04)

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