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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 04:43:16 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
09/12/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20220912144619
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:
12:15 PM
MET WITH:Lisa Gerr, Administrrator; Emily Gerr, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not meet resident’s needs.
Facility did not arrange timely medical attention for resident.
Facility failed to notify resident’s authorized representative of bruising.
Facility Administrator is not present at the facility.
Administrator is not responding timely to responsible party’s communications.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) 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, 11/7/2022; interviewed responsible parties on 11/2/22, and reviewed relevant documentation obtained.
On the allegation: Facility did not meet resident’s needs. It was alleged that R1 was dressed inappropriately during a heat wave. Based on interviews, RP1 visited R1 on 9/4/2022 at approximately 5:45 pm and observed R1 was wearing a long sleeve shirt. The location of the facility experienced a heatwave on this day. The National Weather Service indicates the high temperature outside on 9/4/2022 was 99 degrees Fahrenheit (F). RP1 stated the temperature inside the facility was approximately 85 degrees F. R1’s physician’s report dated 4/10/2022 indicates R1 has dementia and needs assistance with dressing and grooming. Facility staff dressed R1 in a long sleeve shirt on a very hot day in the area where this facility is located. RP1 changed R1 into a short-sleeved shirt during the visit. Although the resident did not sustain any medical issue or injury as
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 7
Control Number 29-AS-20220912144619
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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a result of this, it shows a lack of good judgment used by staff in dressing a resident inappropriately for the weather. The allegation is Substantiated, but a Technical Violation is issued in lieu of a citation.
On the allegation: Facility did not arrange timely medical attention for resident. LPA reviewed text messages between RP1 and the Licensee. Based on interviews with RP1 and the text message records, on 9/5/2022 at 1:12 pm, Licensee acknowledged receiving text messages from the day before showing a large bruise on R1’s left arm. RP1 expressed concerns about the bruise on R1’s left arm and wanted R1 seen by hospice to assess if further medical treatment was needed. Licensee stated they texted the photos to R1’s hospice nurse. Licensee stated they were not sure what time the hospice nurse was coming that day and asked RP1, “Can you call [the hospice nurse] directly as well and try and find out her schedule.” Licensee also forwarded contact information for the hospice nurse to RP1. At 1:59 pm on 9/5/2022, RP1 texted Licensee the hospice nurse “will be there shortly.” The Licensee and facility staff should have sought medical attention for R1, rather than instructing a resident’s family member to do it. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility failed to notify resident’s authorized representative of bruising. RP1 visited R1 on 9/4/2022. R1 was wearing a long sleeve shirt even though it was a very hot day and the inside of the facility was also very warm, around approximately 85 degrees F. RP1 helped R1 change into a short-sleeved shirt and did not notice any bruising. RP1 visited R1 again on 9/5/2022. RP1 noticed R1 was wearing the same shirt from the day before that RP1 put on R1 and noticed a large bruise on R1’s left arm. RP1 provided photographs of the bruise to LPA. LPA observed bruising large in size on R1’s left arm, from the lower shoulder area down to almost the elbow. LPA noted the bruise is darker toward the bottom and is a lighter color at the top. RP1 asked the Care Director about the bruise, and the Care Director admitted knowledge of the bruise. Care Director stated she texted all the caregivers to ask about the bruise, but no one knew what happened. RP1 asked Care Director why RP1 was not contacted about the bruise, and the Care Director stated the Licensee knows about it. LPA reviewed a text message from 9/4/2022 from the Licensee/Administrator to R1’s hospice nurse. The text shows a screenshot of another conversation between the Administrator and a staff, reflecting a picture of the bruised arm with the staff stating they just looked at R1’s arm and R1 had a big bruise on the left arm. The text states it is green on the upper part and purple on the lower part of the arm. The Administrator sent a text message to the hospice nurse that the bruise was observed for the first time that day and none of the staff were sure how R1 received the bruise. The investigation revealed staff and Administrator/Licensee observed the large bruise on R1 on 9/4/2022 but did
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 7
Control Number 29-AS-20220912144619
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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not notify R1’s responsible party about the bruise until after R1’s responsible party had already observed the bruise themselves on 9/5/2022. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility Administrator is not present at the facility. At the time of the complaint, Dana Newquist is listed as the Administrator on record with CCL for this facility. Lisa Gerr, Licensee, also identifies herself as the Administrator. RP1 stated another staff/back-up Administrator Emily Gerr, also identified themselves as the Administrator. During LPA’s visit on 9/14/2022, Emily Gerr identified herself as the Administrator, as did Lisa Gerr. On incident reports submitted to CCL by the facility on 10/11/2022 and 10/13/2022, Emily Gerr is listed as the Administrator. Based on interviews with RP1 and Lisa Gerr, LPA confirmed Dana Newquist is not the Administrator overseeing the facility. Dana Newquist is not present at the facility an adequate amount of time to manage and administer the facility, and the record needs to be updated to reflect the accurate administrator. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Administrator is not responding timely to responsible party’s communications. LPA reviewed email records, and interviewed Licensee and RP1. RP1 discovered a large bruise on R1’s arm on 9/5/2022. RP1 asked the Care Director about it, and the Care Director indicated they texted all the caregivers to ask what happened, but no one knew how R1 sustained the bruise. RP1 asked Care Director and back-up administrator if the cameras could be checked to see if they captured how R1 sustained the bruise. Back-up administrator stated they would ask the Licensee, and later stated the Licensee would review the video and call RP1. On 9/6/2022 at 6:41 am, RP1 sent Licensee an email asking how R1 obtained the bruise on the left arm. On 9/7/2022 at 12:01 pm, the email records show RP1 emailed the licensee again. The email records do not show that the licensee responded to RP1 timely. RP1 indicated on 9/9/2022 that they still had not received a response from the licensee as of 2:18 pm. The Licensee did not respond to RP1’s emails asking for more information about how R1 sustained a large bruise for at least 3 days, and no other staff contacted RP1 with the requested information. Therefore, 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 deficiencies were 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 7
Control Number 29-AS-20220912144619
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)
Deficiency Dismissed
Type B
03/28/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. When changes such as…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement was not met as evidenced by:
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Licensee agreed to submit written statement of understanding of CCR 87466 in its entirety.
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Based on interview and record review, the licensee did not comply with the above cited section when the licensee waited at least one (1) day to inform R1’s responsible person of a large bruise, which posed a potential health and safety risk to residents in care.
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Deficiency Dismissed
Type B
03/28/2023
Section Cited
CCR
87405(a)
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87405(a) Administrator – Qualifications and Duties. All facilities shall have a qualified and currently certified administrator…The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.
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Licensee agreed to submit updated documentation to change the administrator to Emily Gerr. Licensee will send a written statement of understanding of 87405 Administrator Qualifications and Duties.
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This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section when the designated administrator was not present a sufficient number of hours to manage the facility, 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 7
Control Number 29-AS-20220912144619
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)
Request Denied
Type B
03/28/2023
Section Cited
CCR
87468.1(a)(9)
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87468.1(a)(9) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives answered promptly and appropriately.

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Licensee agreed to submit written statement of understanding of 87468.1 Personal Rights of Residents in All Facilities.
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This requirement was not met as evidenced by:
Based on interview and record review, the licensee did not comply with the above cited section when the licensee did not respond to RP1’s communications for over 3 days, which posed a potential health and safety risk to residents in care.
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Deficiency Dismissed
Type B
03/22/2023
Section Cited
CCR
87465(a)(1)
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Type B 87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidenced by:
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Licensee agreed to submit a signed statement of acknowledgement in its entirety of section 87465 Incidental Medical and Dental Care.
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Based on interview and record review, the licensee did not comply with the above cited section when they instructed family members to obtain medical attention for R1 instead of the facility staff arranging it, 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: 5 of 7
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
09/12/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20220912144619

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:
12:15 PM
MET WITH:Lisa Gerr, Administrator; Emily Gerr, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained a bruise.
Medication was not given as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) 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, 11/7/2022; interviewed responsible parties on 11/2/22, and reviewed relevant documentation obtained.
On the allegation: Due to staff neglect, resident sustained a bruise. It was alleged that due to staff neglect, Resident 1 (R1) sustained a large bruise on the left arm and a small bruise on the forehead. LPA reviewed a text message from 9/4/2022 from the Licensee/Administrator to R1’s hospice nurse. The text shows a screenshot of another conversation between the Administrator and a staff, reflecting a picture of the bruised arm with the staff stating they just looked at R1’s arm and R1 had a big bruise on the left arm. The text states it is green on the upper part and purple on the lower part of the arm. The Administrator texted the hospice nurse that it was observed for the first time that day and none of the staff were sure how R1 received the bruise. The text states that R1 does not frequently allow staff to help R1 with dressing or showering so they are unable to see the full skin and observe it for changes in integrity. (Please continue to 9099-C, Pg 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: 6 of 7
Control Number 29-AS-20220912144619
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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 LPA reviewed R1’s physician’s report dated 4/10/2022, which does not state that R1 was a fall risk. LPA reviewed R1’s preplacement appraisal dated 4/1/2022, which indicates R1 had a previous fall in 2021 but recovered well, does not need assistance with transferring but rather needs prompting, and does not need help moving about the facility.
LPA reviewed R1’s appraisal dated 8/31/2022. This appraisal indicates the resident is able to ambulate but is a high fall risk.
LPA reviewed R1’s appraisal dated 9/3/2022. The appraisal notes that R1 is very resistant to physical care and touch, becomes violent and assaults care staff, notes R1 is able to walk without any physical assistance and is able to use stairs if necessary, is able to walk without assistance and can transfer independently, but can become unsteady and is monitored for risk of fall. The appraisal notes that due to wandering after sundown, R1 was reassessed to require a one-on-one private caregiver between 8 pm until R1 goes to bed between 2 am and 5 am. LPA interviewed staff about R1. Staff interviewed indicated R1 was very resistant to care and frequently hit staff, would not sleep at night and instead wandered around. All staff interviewed stated they did not know how R1 obtained the bruise. Based on the information obtained, there was insufficient evidence to substantiate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
On the allegation: Medication was not given as prescribed. It was alleged that R1’s cannabis gummies were not given as prescribed. LPA reviewed medication records including R1’s Centrally Stored Medication Record and MAR for August and September 2022. LPA observed Cannabis infused pomegranate gummies 1:1 THC:CBD to be taken by R1 at 3 pm or 3:30 pm. LPA observed all medication appeared to be given as prescribed based on the documentation provided. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. However, although LPA observed the gummies on the MAR, they were not listed on the Centrally Stored Medication Record; a Technical Violation will be issued for this violation.

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: 7 of 7