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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880993
Report Date: 01/05/2024
Date Signed: 01/05/2024 08:54:46 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
10/03/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231003142743
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: 5DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Anahit Mesropyan, Licensee/AdministratorTIME COMPLETED:
09:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee not advising responsible party when resident was taken to hospital
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Anahit Mesropyan and informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff, reviewed records, and obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 – Licensee not advising responsible party when resident was taken to hospital. It was alleged that when Resident One (R1) was transported to the hospital to care for a medical condition, staff did not notify R1’s responsible party. Record review indicated that R1 has two responsible parties. After a review of evidence that was
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
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
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
10/03/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231003142743

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: 5DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Anahit Mesropyan, Licensee/AdministratorTIME COMPLETED:
09:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee not providing responsible party access to resident records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Anahit Mesropyan and informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff, record review, and obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 – Licensee not providing responsible party access to resident records. It was alleged that the Licensee did not provide Resident #1 (R1’s) responsible party access to R1’s records. Interviews were conducted with staff, as well as other relevant sources, and through those interviews, the records were available for review, but it was
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20231003142743
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: 01/05/2024
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
found undetermined if the records were in fact, refused to be provided for review. Therefore, the allegation could not be corroborated, nor refuted. There were no other witnesses or evidence available at this time to examine; therefore, the 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 along with a copy of the LIC811.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20231003142743
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: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
87468.1(a)(8)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training on the cited regulation. Training due by 5pm on POC date.
8
9
10
11
12
13
14
Based on interviews, and record review, Licensee did not notify R1's representative when R1 was sent to the hospital. This poses a potential health and safety risk to residents in care.
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: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20231003142743
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: 01/05/2024
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
obtained through staff, and other interviews, LPA determined that R1’s representative was not notified of R1’s visit to the hospital. Thus, the regulatory requirement to keep R1’s representative regularly informed was not met. The allegation was therefore, 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 provided along with a copy of the LIC9099D, LIC811, and Appeal Rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5