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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440129
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:08:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20241119151951
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: 173DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Memory Care Manager,Deanne RehbergTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff are preventing resident from leaving the facility
INVESTIGATION FINDINGS:
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On 11/26/20224 at 1:30 PM, Licensing Program Analyst (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Memory Care Manager Deanne Rehberg, and explained the purpose of the visit.

During the course of the investigation, LPAs interviewed W1, S1,R1 and reviewed R1s file. LPAs also toured the memory care unit.

Documentation in R1s file showed that R1 was admitted to the facility on 09/13/2024 with diognosis of dementia as documented on the physician report dated 07/23/2024. By reviewing the physicians report, LPAs observed that the physician statead that R1 cannot leave the facility unassisted. R1 is currently residing in the memory care unit at the facility.R1 was transferred from another Masonic Facility due to exhibiting dangerous behavior. That faciility deoes not have a memory care unit so was not able to meet R1's increased level of care.

**REPORT TO CONTINUE ON 9099 C**

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20241119151951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ADULTS
FACILITY NUMBER: 011440129
VISIT DATE: 11/26/2024
NARRATIVE
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**REPORT CONTINUED FROM 9099**

LPAs interviewed S1. S1 stated that she has worked at the facility for about one year and has known R1 since R1 was admitted to the facility. S1 further stated that she well aware of R1's desire to move back to southern California and that R1 does not accept the fact that she has the diagnosis of Dementia. S1 stated that from time to time, she is able to get R1 to participate in the activities at the facility and that R1 seems to enjoy herself during that time. S1 stated that she feels that R1 is appropriately placed in the memory care unit..

LPAs interviewed R1 who stated that she is very unhappy and she wants go back to southern California to be with her friends. R1 does not think that she needs to live in Memory Care. R1 further stated that she is very unhappy with the fact that she was moved here against her will and feels like she should be able to determine where she lives and with who. R1 would like to live with a friend she has in southern California.

LPAs interviewed W1 who stated he has known R1 for about four years. He lived at the same facility as R1 in southern California. W1 stated that R1 was recently diagnosed with dementia, and her driver license was taken away and needed a higher level of care that was not available at the facility in Southern California. W1 stated that he is very happy with the level of care that R1 is receiving at her current facility. W1 also knows that R1 is not happy and and refuses to accept that she has dementia and needs a higher level of care.

This agency has investigated the complaint alleging facility staff are preventing resident from leaving the facility. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2