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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801866
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:04:44 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20200904143256
FACILITY NAME:MISSION VILLAFACILITY NUMBER:
425801866
ADMINISTRATOR:LISA G. GERRFACILITY TYPE:
740
ADDRESS:321 WEST MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:0CENSUS: 12DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Lisa Gerr, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident in care was unlawfully evicted.
Facility mismanaged medications.
Facility crushed medications without a physician's order.
Facility staff did not meet the needs of a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit to issue final findings. LPA met with Lisa Gerr, Administrator to explain the purpose of the visit. The investigation was started on 9/10/2020. During the investigation, LPA interviewed the administrator on 8/25/2021 at approximately 4:03 pm and 9/10/2021 at approximately 2:00 pm, Staff 1 on 9/11/2021 at approximately 9:47 am, a credible witness on 9/10/2021 at 3:07 pm and Resident 1 (R1)’s responsible party on 9/10/2021 at 4:01 pm. LPA also obtained and reviewed relevant documents on 9/10/2021.

Allegation #1: Resident in care was unlawfully evicted. On 8/25/2020 at approximately 11:30 am, Licensee/Administrator contacted R1’s Responsible Party via telephone to notify Responsible Party that R1 was being “discharged” from the facility at 4:00 pm and Responsible Party needed to come to the facility to pick up R1 and R1’s belongings.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 29-AS-20200904143256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 425801866
VISIT DATE: 03/30/2022
NARRATIVE
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 Documents obtained revealed on 8/25/2020 at 3:46 pm, facility submitted LIC624 reporting that after an incident of agitation, Administrator Lisa Gerr contacted R1’s responsible party to arrange R1’s “discharge” from the facility. The self-reported incident states the administrator contacted R1’s responsible party on 8/24/2020 at 8:00 pm to discuss the situation and explained that Mission Villa “was not the right fit” for R1’s specific needs. The incident report also states, “discharge arrangements were made for 8/25/2020 at 4 pm.” On 8/25/2021 at 4:03 pm, LPA Kontilis contacted Administrator Gerr via telephone wherein Administrator Gerr confirmed that R1 had been officially discharged from the facility due to R1 “not being a good fit”.
An interview conducted with R1’s responsible party revealed they were given less than 24 hours notice for R1 to “discharge” from the facility and made alternate care arrangements for R1. R1’s responsible party noted the facility was trying to “patient dump” R1 after less than 2 days at the facility. Based on records reviewed and interviews conducted, it has been determined that Licensee/Administrator did not submit a proper letter of eviction to CCL, nor did Licensee/Administrator provide Responsible Party with a proper letter of eviction. Therefore, the allegation that Resident in care was unlawfully evicted is Substantiated at this time.
Allegation #2: Facility mismanaged medications. R1’s responsible party stated they were not given R1’s medications when R1 moved out of the facility. R1’s responsible party stated they had to call the Administrator after R1 moved out to ask for R1’s medications and medication list/doctor’s orders. R1’s responsible party stated the Administrator offered to deliver the medications to the responsible party’s home address. LPA also reviewed a text message between R1’s responsible party and the Administrator after R1 moved out of the facility. The Administrator stated she will “grab” the medications and documents and bring them to R1’s responsible party’s home address. During an interview, Administrator confirmed she delivered the medications and documents at R1’s responsible party’s home. Therefore, the allegation that Facility mismanaged medications is Substantiated at this time.
Allegation #3: Facility staff crushed medications without a Physician’s order. On 8/24/2020 around 9:30 pm to 10:00 pm, the Administrator called R1’s responsible party to notify them that R1 was not letting staff provide care. R1’s responsible party asked if R1 had received their 6:00 pm medications. Administrator stated they did not give R1 their 6:00 pm medications. R1’s responsible party stated the administrator put the phone down and that R1 took the medications “crushed up in a juice drink”. R1’s responsible party stayed on the phone and tried to talk R1 through letting the staff provide care. During an interview, Staff 1 (S1) stated they crushed R1’s medications and mixed them with applesauce, then put them in R1’s juice. LPA reviewed a text message between R1’s responsible party and the Administrator before R1 moved out of the facility. The
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200904143256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 425801866
VISIT DATE: 03/30/2022
NARRATIVE
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Administrator stated they were able to “include” R1’s morning medications in R1’s breakfast, which camouflaged the medications. The facility could not provide any crush orders written by R1’s physician allowing staff to crush R1’s medications. Based on records reviewed and interviews conducted, it has been determined that facility staff crushed R1’s medications without a written physician order. Therefore, the allegation that Facility staff crushed medications without a Physician’s order is Substantiated at this time.
Allegation #4: Facility staff did not meet the needs of the resident. R1 was admitted into the facility on 8/23/2020. On 8/24/2020, the Administrator called R1’s responsible party and stated that R1 was demonstrating confusion and disorientation resulting in aggression to staff. The facility submitted five incident reports for four incidents that occurred at different times on 8/24/2020. One self-reported incident report states the administrator contacted R1’s responsible party at 8:00 pm to discuss the situation and explain that Mission Villa “was not the right fit” for R1’s specific needs. The incident report also states “discharge arrangements were made for 8/25/2020 at 4 pm.” Interviews with R1’s responsible party revealed R1 was upfront with the Licensee and Administrator about R1’s combative, loud, and difficult behavior. R1’s preplacement appraisal from 8/3/2020 states confusion, forgetfulness, and not social outside the home. R1’s Physician’s Report dated 8/24/2020 indicates R1 is confused/disoriented, has inappropriate behavior, aggressive behavior, wandering behavior, sundowning behavior, is unable to follow instructions. The facility was unable to provide a Physician’s Report for R1 before R1 moved into the facility. R1’s responsible party emailed the Licensee and Administrator on 8/6/2020 stating concerns that they did not want R1 to move in and then be evicted for their behaviors. The Licensee and Administrator replied stating that would not be an issue. On 9/10/2021, LPA obtained a copy of a letter dated 8/25/2021 addressed to R1’s Responsible Party from Facility’s Licensee Dana Newquist stating the facility is not able to provide the care R1 needs. Based on interviews and records reviewed, the Licensee/Administrator was aware of R1’s behavior before R1 moved into the facility and chose to accept R1 as a resident. The facility did not meet R1’s needs when they requested that R1 be “discharged” from the facility due to their behaviors two days after moving in. Therefore, the allegation that Facility staff did not meet the needs of the resident is Substantiated at this time.

Exit interview conducted. Deficiencies cited on 9099-D. Report emailed. Appeal rights emailed.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20200904143256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 425801866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
87224(a)(4)
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87224(a)(4) Eviction Procedures. (a)(4) The licensee may, upon thirty (30) days written notice to the resident, evict the resident for one or more of the following reasons…

This requirement is not met as evidenced by:
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Facility has closed.
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Based on interviews and record review, the Licensee/Administrator did not ensure that they provided R1 with a proper eviction notice when R1 was given less than a 24-hour eviction notice, which posed an immediate health and safety risk to resident(s) in care.
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Type A
03/30/2022
Section Cited
CCR
87468.1(a)(12)
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87468.1(a)(12) Personal Rights. Residents…shall have all of the following personal rights: …to keep and use their own personal possessions…

This requirement was not met as evidenced by:
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Facility has closed.
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Based on interviews and record review, the Licensee/Administrator did not ensure that R1’s medications and documents were provided to R1 when R1 moved out of the facility, which posed an immediate health and safety risk to resident(s) 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200904143256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 425801866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
87465(a)(5)(D)
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87465(a)(5)(D) Incidental Medical and Dental Care. Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
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The facility has closed.
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 This requirement was not met as evidenced by: Based on interviews and record review, the Licensee/Administrator did not ensure that the facility had a written order from R1’s physician to crush R1’s medications and mix them into other substances, which posed an immediate health, safety, and personal rights risk to resident(s) in care.
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Type A
03/30/2022
Section Cited
CCR
87464(d)
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87464(d) Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal…
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The facility has closed.
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This requirement was not met as evidenced by:
Based on interviews and record review, the Licensee/Administrator did not meet R1’s needs when they illegally evicted R1 after two days at the facility, which posed an immediate health, safety, and personal rights risk to resident(s) 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5