425850204-2-16-2024-29-AS-KKOS-D2HVU6-20240216154413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 02/16/2024
Date Signed: 02/16/2024 03:45:49 PM

Document Has Been Signed on 02/16/2024 03:45 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:	NEWQUIST, DANA		FACILITY TYPE:	740
ADDRESS:	321 W MISSION STREET		TELEPHONE:	(805) 898-2709
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY: 14		CENSUS: 14	DATE:	02/16/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Emily Gerr, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. 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 receiving hospice services and no bedridden residents residing in the facility.
Staff records were reviewed for health screenings, tranings, and current First Aid/CPR certification. All staff have received a criminal background clearance.
At approximately 1:25 pm, LPA observed four smoke alarms located in the breakfast knook, dining area, north end of the hallway, and south end of the hallway with extremely weak or no signals.

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

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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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Document Has Been Signed on 02/16/2024 03:45 PM - It Cannot Be Edited

Created By: Kristin Kontilis On 02/16/2024 at 03:30 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: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted, the Licensee did not comply with the section cited above as four smoke alarms were observed to have no signals and/or extremely weak signals which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2024
	Plan of Correction
1 2 3 4	Licensee agrees to replace four smoke alarms by 5:00 pm on 2/17/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley

LICENSING EVALUATOR NAME:

Kristin Kontilis

LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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