Mission Villa West

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Caregiver Maria Pacleb. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over. The facility has an approved hospice waiver for three (3), and bedridden waiver for one (1). During today’s inspection there were five (5) residents in care. LPA and Caregiver Maria Pacleb toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregiver Maria Pacleb, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (Continued on Page 2, LIC809-C) (Continued from Page 1, LIC809) LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D page). Plans of Correction were jointly developed with the Caregiver Maria Placeb. LPA also provided instruction on a Technical Violation (TV) regarding first aid supplies (refer to the LIC9102-TV page). An exit interview was conducted with Caregiver Maria Pacleb to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers, LPA David Roman, LPA Juliana Barfield and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs and LPM were welcomed by and discussed the purpose of the visit to Caregiver Maria Pacleb. Administrator Amsal arrived during the visit. The facility's license shows a maximum capacity of 6 non-ambulatory residents, of which 1 may be bedridden in room #1. During today’s inspection there were 5 residents in care. LPAs and LPM with Adminstrator Amsal toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Amsal, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and residents, and reviewed facility records. During review of resident records LPAs observed that Resident #1-4 (R1-R4), residents with a major neurocognitive disorder, did not have an updated medical assessment and reappraisal. LPAs observed that Staff #1-3 did not have proof of training and a health screening report in their files. Three deficiencies and one technical violation were cited in accordance with CCR Title 22. An exit interview was conducted with Amsal to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Licensee did not administer medication as prescribed Staff did not treat resident with dignity Staff handled resident roughly, resulting in bruising Licensee did not assist resident(s) with incontinence care

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to the facility. LPA was met at the entrance by Administrator, Amsal Engdaw and Caregiver, Teresita Yap. After introducing and identifying himself, LPA was allowed in the facility. LPA discussed with Ms. Engdaw, the purpose of the visit which was to initiate a complaint investigation. Upon conclusion of the visit, LPA delivered findings to Ms. Yap. There were two (2) staff, and five (5) residents present on the day of LPA’s visit. During the visit, LPA conducted a health and safety check and did not observe any health and safety concerns. On May 3, 2024, Community Care Licensing Division (CCLD) received this complaint. The allegations reported include; licensee did not administer medication as prescribed, did not assist residents with incontinence care, did not treat residents with dignity and handled residents roughly, resulting in bruising. Unsubstantiated The Department’s investigation consisted of facility inspection, review of facility and resident records and interviews with pertinent residents, staff, and outside sources. The facility is licensed to serve six elderly non-ambulatory residents, one of whom may be bedridden, and three residents receiving hospice care. LPA reviewed resident, facility, and hospice care records. The records were complete. LPA observed resident medications were packaged, organized and revealed no indication staff does not administer medications as prescribed. Interviews with residents and record reviews produced no evidence that staff do not provide incontinent assistance. Per interviews with staff, staff rotates residents every two hours and changes undergarments as needed. Residents said they were regularly rotated and changed. None of the residents expressed concerns with any of their care. None of the residents stated that staff does not afford them dignity and respect. Residents also provided no information to support the allegation that staff handles them roughly. Staff denied handling residents roughly or treating them without dignity. Staff interviews did not give LPA any indication that they do not regularly provide resident’s assistance with Activities of Daily Living (ADL). During the inspection, LPA observed the facility to be neat, organized and clean. Residents were wearing clean clothing and bedding appeared clean without offensive odors. Outside source interviews offered no information to substantiate the allegations. The Department has investigated the aforementioned allegations. Based on interviews, LPA observation and review of facility and hospice records, LPA found insufficient evidence to prove the allegations occurred as reported. The preponderance of evidence standard was not met; therefore, the allegations are Unsubstantiated. An exit interview was conducted with Ms. Yap, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) were provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 08-AS-20240503163357

Type of visit: Collateral

Licensing Program Analyst (LPA), Ramon Serrano, conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPA was allowed entry by Caregiver Teresita Yap and discussed the purpose of the visit. During the visit, LPA conducted interviews with resident and staff and obtained facility records. An exit interview was conducted with Teresita Yap and copy of this report along with Licensee Rights was provided to Teresita Yap whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Apr 18, 2024