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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880993
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:10:18 PM

Unsubstantiated


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
01/26/2024 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240126161108
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: 6DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Anahit Mesropyan - AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff neglect resulted in resident's change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Crystal Colvin and Stephanie Martinez conducted an unannounced visit to the facility for the purpose of conducting a complaint investigation for the above allegation. LPAs Colvin and Martinez met with Administrator Anahit Mesropyan and advised her of the purpose of today's inspection. Below is a summary of the investigation.

Regarding allegation "Staff neglect resulted in resident's change in condition" - LPAs Colvin and Martinez conducted interviews with residents, staff, and other outside parties with information relevant to the complaint. LPAs additionally reviewed records in Resident 1's (R1) file. According to interviews conducted, there has been no noticable change in R1's medical condition, and R1 remains at their baseline, though has recently been refusing medications. LPA Colvin confirmed that the facility staff have been communicating the refusals to R1's Hospice Agency that oversees his care and there are no concerns with R1's Hospice care team. Therefore, due to lack of evidence to support the allegation, the findings of the allegation "Staff neglect resulted in resident's change in condition" are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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 2
Control Number 18-AS-20240126161108
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: 01/30/2024
NARRATIVE
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A finding of UNSUBSTANTIATED means 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 with Administrator Anahit Mesropyan and a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2