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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880993
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:25:28 AM

Document Has Been Signed on 10/05/2023 10:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Anahit Mesropyan, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to investigate a complaint #18-AS-20231003142743. During today's inspection, LPA Gardner observed the following deficiency, which was reviewed with Administrator Anahit Mesropyan:

Reporting Requirements - Through interview with staff, and record review, LPA discovered that Resident 1 (R1) had went to the hospital via ambulance to treat a possible medical episode that they were experiencing. Deficiency was cited for not reporting the incident to the Department within the specified time frame as noted in Title 22.

An exit interview was conducted where a copy of this report was discussed with along with copies of the LIC811, LIC809D, and Appeal Rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/05/2023 10:25 AM - It Cannot Be Edited


Created By: Jesse Gardner On 10/05/2023 at 09:41 AM
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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by:
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Licensee agrees to review the regulation, and submit in-service training with all staff on the cited regulation. Additionally, Licensee to submit Unusual Incident Report to the Department by POC date.
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Based on interview withe staff, and record review, LPA determined that there was not a report submitted to the Department in reference to R1 going to the hospital to treat their medical condition. This poses a potential health and safety and personal rights risk to residents in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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