Inspection Reports for
Mission Villa

The facility was generally clean and well-maintained with adequate supplies and safety equipment. However, deficiencies were cited related to incomplete personnel records and lack of verification for staff trainings and orientations.

The facility was generally found to be clean and well-maintained with adequate staffing and supplies. However, deficiencies were cited related to incomplete personnel records and lack of verification of staff trainings and orientations.

This visit was a follow-up to a complaint investigation (29-AS-20250501113652).

The Licensing Program Analyst observed residents unattended near an open laundry room door and found a resident inside the laundry room unresponsive. Additionally, hazardous items including bleach and tide-pods were found unsecured in a floor cabinet, posing a potential risk to residents. A citation was issued for unsafe storage of dangerous items.

This visit was a follow-up to a complaint investigation (29-AS-20250501113652).

The inspection found residents unattended near an open laundry room door and a resident inside the laundry room who was unresponsive. Additionally, hazardous items including a gallon jug of bleach and approximately 30 'tide-pods' were found unsecured in a floor cabinet, posing a potential danger to residents.

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 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 Resident 1 that Staff 1 punched them during a brief change. The allegation was reported to the licensing agency and police. The staff member was placed on administrative leave pending investigation. The report of suspected abuse was submitted late, on 10/23/2025, after the incident on 10/15/2025.

The licensee failed to submit a written report of suspected adult/elder abuse within seven days as required by regulation, posing an immediate health and safety risk to residents. An internal investigation was ongoing, and the staff member involved was placed on administrative leave.

The complaint was substantiated. The allegation was that staff were not assisting residents with personal care, specifically oral hygiene. Interviews and observations confirmed the allegation, with some residents and responsible parties reporting inadequate teeth brushing assistance.

The investigation substantiated the allegation that residents were not consistently receiving assistance with oral hygiene, including teeth brushing. Interviews with residents, responsible parties, and staff confirmed that some residents refused teeth brushing, and staff did not always document refusals or notify families unless refusals were consistent. The facility was cited for failing to ensure residents received proper oral hygiene assistance, posing a potential risk to residents' health and personal rights.

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 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 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.

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.

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 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 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 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 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.