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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 02/21/2025
Date Signed: 02/25/2025 10:45:32 AM

Document Has Been Signed on 02/25/2025 10:45 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MISSION VILLAFACILITY NUMBER:
425850204
ADMINISTRATOR/
DIRECTOR:		EMILY A. GERRFACILITY TYPE:
740
ADDRESS:321 W MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 15CENSUS: 13DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Emily Gerr, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were four (4) staff on duty and thirteen (13) residents in care. LPA met with Emily Gerr, Administrator and explained the purpose of the visit.
Entrance interview conducted:
The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fourteen (14) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for fifteen (15) non-ambulatory residents and a hospice waiver for six (6) residents. Currently, there are three (3) residents on hospice residing in the facility.
LPA toured the facility with Administrators Emily Gerr. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility.
Residents participate at will in activities such as entertainment with live music, karaoke, board and card games, arts and crafts, NatureTrak, Cycling without Age, and general outings to parks, museums, and special events.
LPA observed a comfortable room temperature throughout the facility. LPA observed the living room and dining area to be neat and clean.
The kitchen area consists of two sinks, a dishwasher, refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron and two dishwashing machines.
At approximately 1:35 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined Staff 1 (S1) has worked in the facility since November 2024 and has not been properly associated to the facility prior to employment.
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MISSION VILLA
FACILITY NUMBER: 425850204
VISIT DATE: 02/21/2025
NARRATIVE
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 The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. There are three (3) fire extinguishers on the premises last serviced on 3/28/2024. There are approximately fifteen (15) smoke alarms and one (1) carbon monoxide detector all in good working order.

Due to time restraints, LPA will return at a later date to conclude the inspection.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 10:45 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/21/2025 at 02:41 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MISSION VILLA
FACILITY NUMBER: 425850204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) Criminal Record Clearance: Request a transfer of a criminal record clearance as specified in Section 87355(c)…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was properly associated to the facility prior to working, residing and/or volunteering, which poses an immediate safety risk to persons in care.
POC Due Date: 02/23/2025
Plan of Correction
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Administrator agrees to have S1 properly associated to the facility prior to working, residing, and/or volunteering in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 10:45 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/21/2025 at 03:00 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MISSION VILLA
FACILITY NUMBER: 425850204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
1569.618(c)(3) Administration and management…The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Administrator, the licensee did not comply with the section cited above as the licensee was unable to provide First Aid/CPR training documents for facility staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator agrees to provide First Aid/CPR training documents via email to LPA no later than POC due date (2/28/2025).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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