331880993-12-12-2023-18-AS-RSTS-CZD4DG-20240110180043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880993
Report Date: 12/12/2023
Date Signed: 12/12/2023 08:32:30 AM

Unfounded

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
11/30/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231130145348

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: 5	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Licensee/Administrator Anahit Mesropyan		TIME COMPLETED:	08:45 AM

ALLEGATION(S):

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Staff spoke inapropriatly to resident
Staff was rough with resident causing injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) made an unannounced initial complaint visit to the above noted facility. LPA met with the Licensee/Administrator Anahit Mesropyan and informed them of the purpose of this visit. During this investigation, LPA conducted a tour of the physical plant, conducted interviews with staff, and received supportive documentation for review. The following was determined.

Allegation #1 – Staff spoke inappropriately to resident. It was alleged that a caregiver told Resident One (R1) that if R1 went into the refrigerator, the caregiver would break R1’s arm. LPA conducted a staff interview, reviewed facility records, and made observations.

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20231130145348

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: 12/12/2023

NARRATIVE

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Allegation #2 – Staff was rough with resident causing injury. It was alleged that R1 sustained a skin tear as a result of a caregiver grabbing them.

Record Review provided by the Licensee indicated that Resident One (R1) did not reside at this location. Based on record review, and observation, this complaint was determined to be Unfounded. An Unfounded finding means that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted where a copy of this report was provided.

This is an amended version of the original report dated 12/4/2023.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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