Inspection Reports for Mission Villa

An unannounced case management incident visit was conducted following an allegation that a staff member punched a resident during care. The visit was to investigate the incident and review related documentation.

The licensee failed to submit a written report of suspected adult/elder abuse within seven days of the occurrence, which poses an immediate health and safety risk to residents. The investigation was ongoing, and a deficiency was cited for the reporting failure.

The complaint involved an allegation by a resident that a staff member punched them during a brief change. The staff member was placed on administrative leave pending investigation. A Report of Suspected Dependent Adult/Elder Abuse (SOC341) was submitted late, on 10/23/2025, after the incident on 10/15/2025. The complaint investigation was ongoing at the time of the visit.

The inspection was an unannounced complaint investigation visit triggered by allegations including improper rate increase without proper notice, failure to follow admission agreements, insufficient staffing, and uncomfortable facility temperature.

The investigation substantiated the allegation that the facility increased a resident's rate without proper notice, citing a violation of California Health and Safety Code 1569.657(a). Other allegations regarding admission agreement violations, insufficient staffing, and uncomfortable temperature were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for the allegation that the facility increased Resident 1's rent by $1,000 without proper notice and failed to provide a copy of the admission agreement. Other allegations about admission agreement violations, insufficient staffing, and uncomfortable temperature were unsubstantiated due to insufficient evidence.

The inspection was a Case Management - Annual Continuation visit to evaluate compliance and care at the Residential Care Facility for the Elderly specializing in memory care.

The facility was observed to be clean, with a comfortable room temperature and proper fire safety equipment. The inspection was not completed due to time restraints and will be continued at a later date.

An unannounced annual required inspection was conducted to evaluate the facility's compliance with licensing regulations and ensure resident safety and care standards.

The inspection found the facility to be generally clean and well-maintained with appropriate activities for residents. However, deficiencies were cited related to staff criminal record clearance and lack of First Aid/CPR training documentation for staff, posing safety risks.

Licensing Program Analyst Kristin Kontilis conducted a Case Management - Annual Continuation visit to evaluate compliance with regulations at the facility.

Four smoke alarms were observed to have no signals or extremely weak signals, posing an immediate health and safety risk. Staff records were reviewed and found compliant with health screenings, trainings, and background clearances.

An unannounced annual required inspection was conducted to evaluate compliance with regulations for the Residential Care Facility for the Elderly (RCFE).

The facility was generally clean and well-maintained with adequate lighting and safety equipment; however, deficiencies were noted including an electrical outlet within reach of a resident's bed, soiled kitchen items in the sink, cluttered kitchen counters with mildew/debris, and unused washer and dryer stored on the patio posing health and safety risks. Additionally, the facility's business license was expired.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/14/2022 regarding staff training deficiencies and insufficient staffing at the facility.

The investigation substantiated that staff did not have sufficient or current medication training and that the facility had insufficient staffing at times, including incidents of staff sleeping on shift or not showing up. Other allegations regarding resident falls due to staff neglect, uncleared staff, and failure to report incidents were found unsubstantiated.

The complaint investigation was substantiated for allegations of improper staff training and insufficient staffing. It was unsubstantiated for allegations of resident falls due to staff neglect, uncleared staff caring for residents, and failure to report incidents.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/12/2022 regarding the facility not meeting resident needs, failure to arrange timely medical attention, failure to notify authorized representatives of bruising, absence of the facility administrator, and untimely communication responses.

The investigation substantiated several allegations including inappropriate dressing of a resident during a heatwave, failure to arrange timely medical attention for a resident, failure to notify the resident's authorized representative about bruising in a timely manner, absence of the designated administrator on site, and untimely responses to communications from the responsible party. Some allegations related to staff neglect and medication administration were unsubstantiated, though a technical violation was issued for medication record discrepancies.

The complaint investigation was substantiated for allegations that the facility did not meet resident needs, failed to arrange timely medical attention, failed to notify the resident's authorized representative of bruising, the administrator was not present adequately, and the administrator did not respond timely to communications. The allegations of staff neglect causing bruising and medication not given as prescribed were unsubstantiated.

The inspection was a required 1-year unannounced infection control annual visit to assess compliance with infection control protocols.

No deficiencies were observed during the visit. All infection control protocols were implemented and followed, including screening, PPE use, isolation procedures, and staff training.

An announced pre-licensing visit was conducted to evaluate the facility for licensing as a Residential Care Facility for the Elderly (RCFE).

The facility was found to be compliant with Title 22 Regulations at the time of inspection. The physical plant, safety equipment, and resident accommodations were all in good condition and appropriate for licensing.

The visit was conducted as part of the original licensing process for the facility, including a telephone call with the applicant/administrator to verify identity and confirm understanding of Title 22 regulations.

The applicant/administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. No deficiencies or violations were noted in the report.