<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880993
Report Date: 04/07/2021
Date Signed: 04/09/2021 01:37:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210401155943
FACILITY NAME:MISSION LAKE VILLA, INC.FACILITY NUMBER:
331880993
ADMINISTRATOR:MESROPYAN, ANAHITFACILITY TYPE:
740
ADDRESS:65045 BLUE SKY CIRCLETELEPHONE:
(818) 807-1338
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 1DATE:
04/07/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Anahit Mesropyan, AdministratorTIME COMPLETED:
12:04 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to admit resident following discharge to facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call and the elements of the allegation with Administrator, Anahit Mesropyan.

Regarding the allegation, "Staff refused to admit resident following discharge to facility," it was alleged Administrator, Anahit Mesropyan, failed to allow entrance to Resident One (R1) following agreeing to admit the resident after their discharge from a higher level of care. The LPA initiated the investigation on this date; the LPA reviewed records and obtained copies of pertinent information. R1 was interviewed and reported Mesropyan made contact with them and agreed to admit them prior to April 01, 2021. R1 reported they arrived at the home on April 01, 2021 and Mesropyan refused to allow them entry. Administrator Mesropyan was interviewed and corroborated the resident's statement. She further indicated, after receiving R1's medical assessment on March 31, 2021, and after observing the resident's additional care needs, she decided the resident was not appropriate for admission. The Administrator failed to evaluate R1's medical assessment
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20210401155943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/07/2021
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
26
27
28
29
30
31
32
prior to agreeing to admit the resident. This posed a potential risk to the resident's health and safety. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Administrator Mesropyan via telephone and a copy of this report was provided to Mesropyan via email.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210401155943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2021
Section Cited
CCR
87456(a)(3)
1
2
3
4
5
6
7
EVALUATION OF SUITABILITY FOR ADMISSION: Prior to accepting a resident for care & in order to evaluate their suitability, the facility shall...: Obtain & evaluate a recent medical assessment. This requirement was not met as evidence by: Based on interviews, the Licensee did not ensure R1's medical
1
2
3
4
5
6
7
Licensee agreed to submit certification that regulations 87456 and 87457 were reviewed and understood.
8
9
10
11
12
13
14
assessment was evaluated prior to agreeing to admit. The Administrator indicated, after receiving R1's medical assessment on 03/31/21, & after observing the resident's additional care needs, she decided the resident was not appropriate for admission. This posed a potential risk to the resident's health/safety.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3