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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850204
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:31:09 PM

Substantiated


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
09/14/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20220914113148
FACILITY NAME:MISSION VILLAFACILITY NUMBER:
425850204
ADMINISTRATOR:NEWQUIST, DANAFACILITY TYPE:
740
ADDRESS:321 W MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:14CENSUS: 12DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Emily Gerr, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff is not properly trained.
Facility has insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Emily Gerr in-person and Lisa Gerr, telephonically and explained the reason for the visit. During the investigation, LPA conducted interviews with staff on 9/2/2022, 11/2/2022, 11/4/2022, and 11/7/2022; interviewed responsible parties on 11/2/22, and reviewed relevant documentation obtained.
On the allegation: Staff is not properly trained. Health and Safety Code sections 1569.69(a)(2) and 1569.69(b) state training requirements for medication assistance in Residential Care Facilities for the Elderly are 10 hours of initial training for new staff, and 8 hours additional training in each succeeding 12-month period for continuing staff. Licensee provided medication training records for S1, S2, S3, S4, and the Licensee via email. LPA confirmed with Licensee that the documents provided for S1, S2, S3, S4 and the Licensee were the complete medication training records for those staff. Facility records show S1 was hired on 7/5/2022. LPA reviewed medication training records and found S1 had 8 hours of medication training total, completed in September 2022, which does not meet the 10-hour requirement for new staff.
Please continue to 9099-C, Pg 2.
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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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 6
Control Number 29-AS-20220914113148
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: 425850204
VISIT DATE: 03/22/2023
NARRATIVE
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Facility records show S2 had 7 hours of medication training in November 2019 and the Licensee did not provide any more current records. S2 does not have sufficient/current medication training. Facility records show S3 had 8 hours of medication training in 2019 and the Licensee did not provide any more current records. S3 does not have sufficient/current medication training. Facility records show S4 had 8 hours of medication training between July and August 2022, which does not meet the 10-hour requirement for new staff. Facility records show licensee had 7 hours of medication training in 2019, 3 hours of medication training in 2018, and did not provide any more current records. Licensee does not have sufficient/current medication training. Based on the evidence obtained, the allegation is Substantiated at this time.
On the allegation: Facility has insufficient staffing. It was alleged that the facility sometimes has one caregiver on shift to handle all 14 residents in the facility. The reporting party notes staff quit mid-shift which left insufficient staff to care for and supervise the residents. LPA reviewed staff schedules for September 1, 2022 to September 18, 2022. LPA observed most of the days have two caregivers per shift. LPA observed one AM caregiver on 9/1/2022, one PM caregiver between 2:30 pm and 4:00 pm on 9/1/2022, and one overnight caregiver between 10:00pm and 6:00am. On 9/2/2022 there was one overnight caregiver, no overnight caregiver listed on 9/4/2022, and one overnight caregiver listed on 9/11/2022.
Staff interviewed stated showers were done on time for the most part. Multiple staff noted if residents refused, the residents were not forced to shower and then staff tried again later. Staff interviewed indicated residents were toileted frequently, and residents with incontinence had their briefs changed on time and frequently checked. On the NOC shift, staff did rounds and made sure residents were clean and dry. Staff interviewed indicated they did not feel there were enough staff at the facility but everyone did their best to meet the residents’ needs. Staff interviewed indicated staff also have other duties including setting the table for meals, making beds, doing laundry, which takes time away from resident care.
Staff interviewed indicated there were incidents where a staff fell asleep on shift and did not provide assistance. LPA reviewed the incident report for this incident, which indicated Resident 5 (R5) needed assistance and attempted to contact the awake-on duty staff but they did not respond. R5 contacted a family member, who came to the facility and entered through a window. Incident report states the staff was terminated for sleeping on the job.
Staff also indicated one time a staff did not show up to their shift due to not setting their alarm and falling asleep, so there was only one staff on the shift instead of two. One staff interviewed indicated they worked in the kitchen, but during a COVID outbreak and decreased staffing, they assisted residents. Staff interviewed

Please continue to 9099-C, Pg 3.

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

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220914113148
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: 425850204
VISIT DATE: 03/22/2023
NARRATIVE
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indicated one person on the NOC shift did not feel there was sufficient staffing. Staff stated sometimes there was only one staff on other shifts as well, whereas usually there were two. Staff also indicated sometimes agency staff were brought in to supplement when needed.
The facility scheduled staff based on residents’ needs, but if the staff were asleep and not working or did not show up to their assigned shifts, the facility had insufficient staffing. Based on the information obtained, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.

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

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220914113148
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: 425850204
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements.
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:

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Administrator agreed to create a plan to ensure sufficient staffing at all times, and discuss staff and supervision expectations with all staff by 3/28/2023
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Based on interview and record review, the licensee did not comply with the above cited section when staff fell asleep on shift or did not show up, which posed a potential health and safety risk to residents in care.
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Request Denied
Type B
03/28/2023
Section Cited
HSC
1569.69
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HSC §1569.69(b) Training Requirements:
Each employee…who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by:
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Licensee agreed to submit proof of current and adequate medication training per 1569.69 by 3/28/2023.
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Based on record review, the licensee did not comply with the above cited section when 5 staff (S1, S2, S3, S4, licensee) did not have adequate training, which posed a potential health and safety risk to residents 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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
09/14/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20220914113148

FACILITY NAME:MISSION VILLAFACILITY NUMBER:
425850204
ADMINISTRATOR:NEWQUIST, DANAFACILITY TYPE:
740
ADDRESS:321 W MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:14CENSUS: 12DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Emily Gerr, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Due to staff neglect, resident fell while in care resulting in fracture.
Uncleared staff caring and supervising residents in care.
Facility is not reporting incidents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Emily Gerr in-person and Lisa Gerr, telephonically and explained the purpose of the visit. During the investigation, LPA conducted interviews with staff on 9/2/2022, 11/2/2022, 11/4/2022, 11/7/2022; interviewed responsible parties on 11/2/22, and reviewed relevant documentation obtained.
On the allegation: Due to staff neglect, resident fell while in care resulting in fracture. It was alleged that two residents at the facility sustained fractures due to staff neglect. LPA reviewed incident reports for the facility for an incident between Resident 1 and 2 (R1, R2). Staff interviewed indicated R1 got into an argument with R2 and was trying to grab a sock from R2. Based on the incident report and interviews conducted, R1 was observed on the facility cameras falling during the incident, but R2 did not push R1. Staff interviewed indicated R1’s fall was just an accident and did not result from insufficient staffing or supervision. During

Please continue to 9099-C, Page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220914113148
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: 425850204
VISIT DATE: 03/22/2023
NARRATIVE
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interviews, staff told LPA that R3 and R4 sustained fractures. LPA did not find any incident reports indicating residents sustained a fracture. There was no record or recollection of R4 falling or sustaining a fracture. Based on the information obtained, there is insufficient evidence to support the allegation that due to staff neglect, resident fell while in care resulting in fracture. Therefore, the allegation is Unsubstantiated at this time.
On the allegation: Uncleared staff caring and supervising residents in care. LPA reviewed a staff roster and a list of fingerprint clearance for this facility. LPA observed during the time of this complaint, S1 was not cleared or associated to the facility. LPA observed that S1 was previously associated to the previous license for this facility. The facility underwent a change of ownership, and records show S1 was disassociated from the facility on 2/18/22, the day that CCL processed the closure for the previous facility. During the closure process, S1 was not associated to the new/current facility, per CCL’s process. It appears an error or technical glitch occurred, as no documentation shows the Licensee tried to disassociate S1. S1 has already been reassociated to the facility. Based on the information obtained, the allegation is Unsubstantiated at this time.
On the allegation: Facility is not reporting incidents. It was alleged the facility did not report incidents of residents striking other residents. LPA reviewed incident reports for 2022 and observed two incidents where there were resident on resident conflicts, on dates 4/29/2022 and 7/6/2022. LPA interviewed staff about serious incidents, and was told R1, R3, and R4 sustained fractures. CCL received an incident report for R1’s fracture. CCL did not receive incident reports for fractures for R3 or R4, but LPA based on the investigation, determined there was no evidence or documentation to show R3 or R4 sustained fractures. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued at the time of the visit.

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

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6