425850204-1-28-2026-29-AS-KKOS-DQS2FF-20260128162129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 01/28/2026
Date Signed: 01/28/2026 04:24:06 PM

Document Has Been Signed on 01/28/2026 04:24 PM - 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 VILLA		FACILITY NUMBER:	425850204
ADMINISTRATOR/ DIRECTOR:	EMILY A. GERR		FACILITY TYPE:	740
ADDRESS:	321 W MISSION STREET		TELEPHONE:	(805) 898-2709
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY: 15		CENSUS: 13	DATE:	01/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Emily Gerr, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 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 two (2) care staff, one (1) housekeeper, and (1) Food Service Manager 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 fifteen (15) 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. There are five (5) residents currently on hospice.
LPA toured the facility with Administrator 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 board and card games, arts and crafts and walks around the facility.
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. LPA observed a sufficient amount of perishables for two days and non-perishables for seven days available to residents in care.

Please continue to 809-C, Pg 2.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/28/2026

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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 3/31/2025. There are approximately four (4) smoke alarms and one (1) carbon monoxide detector all in good working order.
LPA reviewed residents records and noted on file are Emergency face sheets, Admission Agreements, Appraisals/Re-Appraisals, Needs and Services Plans, and health screenings. LPA noted one resident’s admission agreement was unsigned and one resident does not have a current admission agreement on file. Technical violation issued.
LPA reviewed personnel records and noted not on file are verification(s) of staff trainings and/or orientations of six out six staff members. LPA noted all staff members have current First Aid/CPR certification, current health screenings, and background clearance records.

Due to time restraints, LPA will return at a later date to continue 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.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2026 04:24 PM - It Cannot Be Edited

Created By: Kristin Kontilis On 01/28/2026 at 03:53 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as LIC501 in Staff 1’s (S1’s) file was incomplete which poses a potential health, safety, or personal rights risk to residents in care.
	POC Due Date: 02/03/2026
	Plan of Correction
1 2 3 4	Administrator agrees to have Staff 1's (S1's) LIC501 complete and in S1's file no later than POC due date. Administrator agrees to provide proof of complete LIC via email directly to LPA.

Type B

Section Cited

CCR

87412(c)

87412(c) Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as Licensee was unable to provide verification that staff trainings and/or orientations have been conducted and/or documented which poses a potential health and safety risk to residents in care.
	POC Due Date: 02/03/2026
	Plan of Correction
1 2 3 4	Administrator agrees to provide documented verification of staff trainings and orientations no later than POC due date. Administrator agrees to send a list of completed trainings and orientations for all staff. Administrator agrees to send the list via email directly to LPA no later than due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Kristin Kontilis
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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