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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880993
Report Date: 10/27/2023
Date Signed: 10/27/2023 09:44:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
09/12/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230912151004
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:
10/27/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Murman Umpriani, CaregiverTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff did not administer resident medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver findings of an investigation into the above allegation. LPA met with Caregiver Murman Umpriani who was informed of the purpose of the visit, and granted entry. LPA then conducted a tour of the facility. The investigation included interviews with staff, residents witnesses, and a review of facility documentation.

It was alleged that staff do not administer medications as required. As alleged, R1’s medications were at the pharmacy and not picked up by the Licensee. LPA conducted a review of medication records at the facility, as well as conducted interviews with staff and residents. Through record review, LPA found that R1 moved into the facility on 4/30/23, with all of their medications, and the facility began administering them.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 5
Control Number 18-AS-20230912151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 10/27/2023
NARRATIVE
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 Interview with Licensee indicated that the Licensee picked up medications for R1 when they were due to be picked up. A receipt was provided to the Department by the Licensee that showed the Licensee picked up medications on 5/24/23 with medication order numbers. Upon examination, this receipt did not include any resident names. Evidence that was provided by a relevant party was examined, and revealed that the Licensee’s list of medications that they picked up, did not include any of R1’s. Thus proving R1’s medications were not, in fact, picked up to be dispensed by the facility. Review of the document indicated that Medication #1 (M1), and Medication #2 (M2) were dispensed on 5/2/23 and had a 30-day supply. M1, and M2 were not again filled until 6/22/23. Thus, this allegation was Substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099D, and Appeal Rights were provided to Licensee/Administrator, Anahit Mesropyan.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230912151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This did not meet the requirement by:
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Licensee agrees to conduct in-service training on the cited regulation, and provide proof of such to LPA by POC date.
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Based on LPA evidence review, the Licensee did not provide medications as ordered by the physician. This is a potential health and safety 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
09/12/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230912151004

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:
10/27/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Murman Umpriani, CaregiverTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff did not safeguard resident personal belongings
Staff not allowing residents to have visitors
Staff not allowing resident to leave facility with responsible party
Staff do not supervise residents in care
Staff do not provide sufficient hygiene for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver findings of an investigation into the above allegations. LPA met with Caregiver Murman Umpriani who was informed of the purpose of the visit and granted entry. LPA then conducted a tour of the facility. The investigation included interviews with staff, residents, outside relevant sources, and a review of facility documentation.

It was alleged that when Resident One (R1) moved out of the facility, staff gave R1 clothes that did not belong to them. Through several relevant witness interviews, it was determined that R1 was given clothes that R1 had in their possession while R1 stayed at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230912151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 10/27/2023
NARRATIVE
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The Department found that through interviews conducted with relevant sources, R1 did not have many things upon arrival, and during their stay, R1’s clothes were purchased by different relevant parties. Due to conflicting information provided by relevant sources, and staff, and no other witness information available, this allegation was Unsubstantiated.

It was alleged that R1 was not able to have visitors during “nap” or “quiet” time. LPA interviewed R1, staff, other residents, and relevant sources, and found that visitors had not been seen turned away by staff to see their residents. This allegation was Unsubstantiated as a result.

It was alleged that R1 was not allowed to leave with R1’s responsible party. LPA conducted interviews with staff and residents and found that R1 was allowed to leave with their responsible party, and LPA reviewed documentation provided by the facility that corroborated this. Resident interviews stated that they were also allowed to leave with their responsible parties and had no concern that staff were preventing them from leaving, thus this allegation was Unsubstantiated.

It was alleged that staff sleep in the facility and do not supervise residents in care. LPA conducted several interviews with residents and staff and found that staff have not been seen to sleep during the day while caring for residents. Due to interviews conducted, as well as a lack of other evidence available, this allegation was Unsubstantiated.

It was alleged that R1 wore the same clothing for several days and looked dingy. LPA conducted interviews with staff, and residents, and found that some residents will wear the same clothing for a couple of days, and one resident interview revealed that it was due to their comfort. Other residents maintained that staff care for their hygiene, and that if residents need a change of clothing, staff assist them with that. Documentation provided by the facility revealed that showers were provided to R1 every 4 days. Interview with R1 revealed that R1 did not feel dirty, nor was in bad hygiene. R1 maintained that staff cared for them. All of the evidence reviewed concluded that this allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was provided to Licensee/Administrator, Anahit Mesropyan along with copies of the LIC811 (confidential names list).
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5