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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 03/23/2022
Date Signed: 03/23/2022 03:18:43 PM


Document Has Been Signed on 03/23/2022 03:18 PM - It Cannot Be Edited

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: 200DATE:
03/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Soledad Martinez, Executive DirectorTIME COMPLETED:
03:40 PM
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On 3/23/2022 at 2:20 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct a Case Management visit to follow-up on facility renovation. Fire clearance was approved on 3/15/2022. LPAs met with Executive Director, Soledad Martinez and explained the purpose of the visit. Fire clearance was approved all non-ambulatory residents.

During the Case Management visit, LPAs toured facility including but not limited to multiple activity rooms, medication room, laundry room, random resident rooms, and dining area. LPA observed smoke and carbon monoxide detector and sprinklers throughout facility. Fire extinguisher was last serviced on 1/20/2022.

No issues during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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