Mission Lake Villa

Allegation investigated: Staff did not administer resident medications as prescribed

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver findings of an investigation into the above allegation. LPA met with Caregiver Murman Umpriani who was informed of the purpose of the visit, and granted entry. LPA then conducted a tour of the facility. The investigation included interviews with staff, residents witnesses, and a review of facility documentation. It was alleged that staff do not administer medications as required. As alleged, R1’s medications were at the pharmacy and not picked up by the Licensee. LPA conducted a review of medication records at the facility, as well as conducted interviews with staff and residents. Through record review, LPA found that R1 moved into the facility on 4/30/23, with all of their medications, and the facility began administering them. Substantiated Interview with Licensee indicated that the Licensee picked up medications for R1 when they were due to be picked up. A receipt was provided to the Department by the Licensee that showed the Licensee picked up medications on 5/24/23 with medication order numbers. Upon examination, this receipt did not include any resident names. Evidence that was provided by a relevant party was examined, and revealed that the Licensee’s list of medications that they picked up, did not include any of R1’s. Thus proving R1’s medications were not, in fact, picked up to be dispensed by the facility. Review of the document indicated that Medication #1 (M1), and Medication #2 (M2) were dispensed on 5/2/23 and had a 30-day supply. M1, and M2 were not again filled until 6/22/23. Thus, this allegation was Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099D, and Appeal Rights were provided to Licensee/Administrator, Anahit Mesropyan. The Department found that through interviews conducted with relevant sources, R1 did not have many things upon arrival, and during their stay, R1’s clothes were purchased by different relevant parties. Due to conflicting information provided by relevant sources, and staff, and no other witness information available, this allegation was Unsubstantiated. It was alleged that R1 was not able to have visitors during “nap” or “quiet” time. LPA interviewed R1, staff, other residents, and relevant sources, and found that visitors had not been seen turned away by staff to see their residents. This allegation was Unsubstantiated as a result. It was alleged that R1 was not allowed to leave with R1’s responsible party. LPA conducted interviews with staff and residents and found that R1 was allowed to leave with their responsible party, and LPA reviewed documentation provided by the facility that corroborated this. Resident interviews stated that they were also allowed to leave with their responsible parties and had no concern that staff were preventing them from leaving, thus this allegation was Unsubstantiated. It was alleged that staff sleep in the facility and do not supervise residents in care. LPA conducted several interviews with residents and staff and found that staff have not been seen to sleep during the day while caring for residents. Due to interviews conducted, as well as a lack of other evidence available, this allegation was Unsubstantiated. It was alleged that R1 wore the same clothing for several days and looked dingy. LPA conducted interviews with staff, and residents, and found that some residents will wear the same clothing for a couple of days, and one resident interview revealed that it was due to their comfort. Other residents maintained that staff care for their hygiene, and that if residents need a change of clothing, staff assist them with that. Documentation provided by the facility revealed that showers were provided to R1 every 4 days. Interview with R1 revealed that R1 did not feel dirty, nor was in bad hygiene. R1 maintained that staff cared for them. All of the evidence reviewed concluded that this allegation was Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where a copy of this report was provided to Licensee/Administrator, Anahit Mesropyan along with copies of the LIC811 (confidential names list).the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 18-AS-20230912151004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 3, 2023

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This did not meet the requirement by: Based on LPA evidence review, the Licensee did not provide medications as ordered by the physician. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee agrees to conduct in-service training on the cited regulation, and provide proof of such to LPA by POC date.

Type of visit: Case Management - Deficiencies

On this date, Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to investigate a complaint #18-AS-20231003142743. During today's inspection, LPA Gardner observed the following deficiency, which was reviewed with Administrator Anahit Mesropyan: Reporting Requirements - Through interview with staff, and record review, LPA discovered that Resident 1 (R1) had went to the hospital via ambulance to treat a possible medical episode that they were experiencing. Deficiency was cited for not reporting the incident to the Department within the specified time frame as noted in Title 22. An exit interview was conducted where a copy of this report was discussed with along with copies of the LIC811, LIC809D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 13, 2023

Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by: Based on interview withe staff, and record review, LPA determined that there was not a report submitted to the Department in reference to R1 going to the hospital to treat their medical condition. This poses a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: Licensee agrees to review the regulation, and submit in-service training with all staff on the cited regulation. Additionally, Licensee to submit Unusual Incident Report to the Department by POC date.

Type of visit: Case Management - Other

On 3/28/22 Licensing Program Analysts (LPA) David Cuevas conducted an unannounced visit to the facility. LPA identified self and was granted entree. LPA met with staff, Murman Umpriani who was informed of the purpose of visit. Licensee/Administrator, Mesropyan, Anahit was called and arrived at the facility shortly after. During this visit LPA identified a individual at the facility that does not have employee file or is associated to the facility. Per Licensee, individual is in the process of being hired, that is why he was at the facility. During this visit both Licensee and identified individual were explained that proper live scan and association is needed for a staff to be present at the facility and provided care and supervision. Both Licensee and LPA escorted individual out of facility during visit. Based on the statement made and observations, deficiency will be given and civil penalties accessed. An exit interview was conducted where this report, LIC 809 D, and appeal rights were reviewed with and provided to Licensee/Administrator, Mesropyan, Anahitthe state’s words, verbatim · CDSS document, Mar 28, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(f) · Plan of correction due date: Apr 5, 2022

Criminal Record Clearance.:An immediate civil penalty of $100 a day shall be assessed if an individual subject to a criminal record review has not obtained a clearance or exemption. This requirement has not been met by During visit it was revealed that an unclear individual was present on the premise of the facility. This poses a safety risk to residents in care. An immediate Civil Penalty has been issued.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: Licensee immediately instructed individual to get a live scan. Individual left the facility during the visit. Licensee informed LPA that she will forward proof to CCLD that the live scan was conducted by 04/05/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA Gardner met with Caregiver Murman Umpriani. There are currently no cases of COVID-19 within the facility. During today's visit, Licensee/Administrator Anahit Mesropyan arrived at the facility during the visit. LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. During the inspection, LPA Gardner discussed infection control practices and procedures with Ms. Mesropyan, and an exit interview was conducted and a copy of this report, was reviewed with and provided.the state’s words, verbatim · CDSS document, Nov 9, 2021

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Tricia Danielson contacted the facility via telephone for purpose of conducting a pre-licensing evaluation. At approximately 1:00 PM, LPA met with facility by Administrator (AD) Anahit Mesropyan via Facetime. An initial application to operate a Residential Care For the Elderly facility (RCFE) was submitted to the Central Applications Unit (CAU) on 07/06/20 for a total capacity of six (6) non- ambulatory residents. On 8/31/2020, a Riverside County Fire Department fire clearance was granted for five (5) non-ambulatory residents and one (1) bedridden resident. Component III completed with AD Mesropyan on this date. LPA Danielson observed the following: Structure: Facility was a one story house with four (4) resident bedrooms, one (1) live in caregiver bedroom, two (2) bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the dining area/hallway to control entire house. Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. Bedrooms #3 or #4 will accommodate a bedridden resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. There was one caregiver bedroom for live in staff. Bathrooms: Both resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. At 1:35 PM, LPA observed AD test water temperatures in both resident bathrooms. LPA verified via Facetime that water temperature measured 108.0 degrees Fahrenheit. (CONTINUED ON LIC 809C) (CONTINUED FROM LIC 809C) evidenced by staff's ring from their cellphone. Pre-Licensing is incomplete with deficiencies to be resolved as soon as possible. A follow up pre-licensure LIC809 will be generated upon resolution of deficiencies. The following items need to be corrected before the facility can become licensed: The posting of the Let-Us-Know and Ombudsman posters. Side gate much have be self latching when released. Applicant will notify LPA of completion of the above items. The license will be granted based on final review by and approval from the Central Applications Unit. (CONTINUED FROM LIC 809) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. Via Facetime, LPA observed the freezer temp at 0 degrees Fahrenheit and the refrigerator at 40 degrees Fahrenheit. LPA observed the stove to be operational. There was adequate seating for meals for all residents. Sample menu was posted on the refrigerator. LPA observed the required 72 hour emergency food supply to be stored in a kitchen pantry. Laundry area with washer and dryer were located in the garage. Living/Family room: There were two separate living/family areas with safe and adequate seating for all residents as well as working TV. Yards/Outside: There was a patio with adequate umbrella covered seating for all residents. Fencing secured the entire backyard. To the right of the front yard a metal gate lead to the backyard. LPA observed that the gate did not self latch when released. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property. Garage: There was a washer and dryer located in the garage. Laundry detergents and cleaning solutions were secured and inaccessible to residents. LPA observed a 72 hour emergency supply water was also located in the garage. Garage was organized and free of obstructions. Emergency Phone Numbers, and Exit Plan: An activity calendar, AD certificate, Emergency Disaster Plan were posted in the entry way. Facility exit plan was posted near the front door. The required Let-Us-No poster and Ombudsman poster were noted to be missing from the facility. General items: Fire extinguisher was charged and mounted in the kitchen and entry way. Seven (7)moke/carbon monoxide alarms were tested and were in working order. Flashlights for use in the event of an emergency were located in each resident room and as well as the hallway. Flashlights were tested and found to be operational. Resident records will be stored in a locked filing cabinet near the kitchen. First Aid kit and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as (CONTINUED ON LIC 809C)the state’s words, verbatim · CDSS document, Dec 11, 2020