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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880993
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:46:34 PM

Document Has Been Signed on 03/28/2022 12:46 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, ANAHITFACILITY TYPE:
740
ADDRESS:65045 BLUE SKY CIRCLETELEPHONE:
(818) 807-1338
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 4DATE:
03/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee, Anahit MesropyanTIME COMPLETED:
12:45 PM
NARRATIVE
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On 3/28/22 Licensing Program Analysts (LPA) David Cuevas conducted an unannounced visit to the facility. LPA identified self and was granted entree. LPA met with staff, Murman Umpriani who was informed of the purpose of visit. Licensee/Administrator, Mesropyan, Anahit was called and arrived at the facility shortly after.

During this visit LPA identified a individual at the facility that does not have employee file or is associated to the facility. Per Licensee, individual is in the process of being hired, that is why he was at the facility. During this visit both Licensee and identified individual were explained that proper live scan and association is needed for a staff to be present at the facility and provided care and supervision. Both Licensee and LPA escorted individual out of facility during visit.

Based on the statement made and observations, deficiency will be given and civil penalties accessed.

An exit interview was conducted where this report, LIC 809 D, and appeal rights were reviewed with and provided to Licensee/Administrator, Mesropyan, Anahit

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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Document Has Been Signed on 03/28/2022 12:46 PM - It Cannot Be Edited


Created By: David Cuevas On 03/28/2022 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
87355(f)

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Criminal Record Clearance.:An immediate civil penalty of $100 a day shall be assessed if an individual subject to a criminal record review has not obtained a clearance or exemption. This requirement has not been met by
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Licensee immediately instructed individual to get a live scan. Individual left the facility during the visit. Licensee informed LPA that she will forward proof to CCLD that the live scan was conducted by 04/05/22.
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During visit it was revealed that an unclear individual was present on the premise of the facility. This poses a safety risk to residents in care. An immediate Civil Penalty has been issued.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
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