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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 01/31/2024
Date Signed: 02/07/2024 07:55:00 AM


Document Has Been Signed on 02/07/2024 07:55 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:NEWQUIST, DANAFACILITY TYPE:
740
ADDRESS:321 W MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:14CENSUS: 14DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Emily Gerr, AdministratorTIME COMPLETED:
05:45 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 five (5) staff on duty and fourteen (14) 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 fourteen (14) non-ambulatory residents of which three (3) may be bedridden, and a hospice waiver for six (6) residents. Currently, there are three (3) residents on hospice and no bedridden residents residing in the facility.
LPA toured the facility with Administrators Emily Gerr and Lisa 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.
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 dishwasher machines. At approximately 12:14 pm, LPA observed numerous plates, cups, bowls, glasses, flatware, and other miscellaneous items in a sink. LPA observed food waste, liquids, and other debris on many of the items. LPA observed four kitchen counters with a clutter-like appearance with kitchen appliances, knick-knacks, vases, and boxes of fruit. Additionally, LPA observed the kitchen counters to have dark mildew/debris between the tile pieces.
At approximately 1:50 pm, LPA observed an electrical outlet with blue tape over the outlet located at the side of the bed in Room 4. LPA observed the outlet to be within close reach of a resident in care.
At approximately 1:55 pm, LPA observed a washing machine and dryer stored on the west patio. LPA observed facility staff removed the equipment at approximately 3:15 pm. <Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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: 01/31/2024
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 At approximately 2:15 pm, LPA observed the facility business license expired as of 5/12/2023. LPA emphasized the importance of a current business license to ensure local fire marshal regulations are observed.
The facility has twelve bedrooms. Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps on the nightstands provide sufficient lighting in each bedroom. The hallway has night lights and ample lighting.
There are three bathrooms throughout the facility. Two of the bathrooms are located off the hallway, one bathroom is located in the laundry room behind the dining area. Residents have access to each bathroom.
LPA observed four fire extinguishers that were serviced on 3/29/2023. LPA observed smoke detectors and one carbon monoxide detector to be in good working order.
Residents will participate in various activities based on their individual interests and preferences, including word games, card games, board games, arts and crafts, painting and drawing, outings to local parks, beaches, museums, Santa Barbara Zoo and local eateries. Exercise classes such as stretch and yoga, floor bowling, and ball toss are also offered.
Visitors from community organizations assist residents in Brain Exercise Initiative (BEI) which includes trivia activities and other mentally stimulating activities.

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



The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies by the correction due date may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were 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: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/07/2024 07:55 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as an electrical outlet was within reach of a resident's bed. Based on observation, soiled items in a kitchen sink were observed, and an unused washer and dryer were onplaced the west patio which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Licensee agrees to cover the electrical outlet within the POC due date. Licensee agrees to provide in writing a plan in place to keep the kitchen clean and sanitary at all times. The Licensee agrees to provide a written plan in place to immediately remove unused equipment from 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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