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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:45:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MASONIC HOME FOR ADULTSFACILITY NUMBER:
011440129
ADMINISTRATOR:SOLEDAD MARTINEZFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 471-3434
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:242CENSUS: 0DATE:
09/01/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Joseph Pritchard, Chief Clinical OfficerTIME COMPLETED:
11:55 AM
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On 9/1/2021 starting at 10:20am, Licensing Program Analyst (LPA) L. Francisco arrived announced to conduct a Case Management for the newly constructed Pavilion Building and met with Chief Clinical Officer, Joseph Pritchard and Executive Director, Soledad Martinez.

The Pavilion Building is a two story building of which memory care is located in the first floor and assisted living is in the second floor. The building has a total of 28 units with a total capacity of 28. LPA L. Fontanilla was provided a copy of the Temporary Certificate of Occupancy (TCO) from City of Union City by Chief Clinical Officer and was also advised by Fire Inspector that facility is ready for inspection.

LPA L. Francisco, Pritchard and Martinez inspected a total of 4 units, 2 on each floor. LPA observed bathrooms in each units were equipped with grab bars and non-skid shower base. Both Memory Care and Assisted Living were equipped with Life line emergency response buttons. Assisted living units were equipped with sink, refrigerator and microwave, and Memory care units were equipped with a sink. LPA observed delayed egresses are installed in memory care floor. Smoke detectors were tested and observed in working condition as well as integrated with the Fire Department. LPA was informed assisted living residents are tentatively scheduled to move in mid-September and end of September for memory care residents.

Based on observation and recommendation from the Fire Inspector, LPA recommends that Pavillion building is ready to admit new residents once Certificate of Occupancy has been approved by the city.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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