Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 05/24/2018
Date Signed: 05/29/2018 10:26:55 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:FRANCO DIAMONDFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 471-3434
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:242CENSUS: 202DATE:
05/24/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Audrey Duckworth, HR Technology & Operations ManagerTIME COMPLETED:
04:00 PM
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On Thursday, May 24, 2018 at 2:30pm, Licensing Program Analyst (LPA), Kimmily Chow-Yau conducted an unannounced visit to verify that an employee that the facility went to get fingerprinted is no longer at the facility or was never hired. The Caregiver Background Check Bureau sent a letter to the facility to indicate the Staff 1 (S1) was being Excluded from being allowed to work at any licensed facility.

LPA meet with HR Technology and Operations Manager, Audrey Duckworth and verified with Volunteer and Community Resources Program Manager, Carlene Voss that S1 was never hired, even though the Confirmation of Removal Form from the facility indicated that S1 was removed on 5/11/18.

Based on evidence obtained during today's visit, the LPA has verified the individual is not present, employed or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500.

Verification is complete.

LPA went over the report with Duckworth and presented a copy for the facility's records.
SUPERVISOR'S NAME: Tracy BarryTELEPHONE: (510) 622-2610
LICENSING EVALUATOR NAME: Kimmily Chow-YauTELEPHONE: (510) 873-6412
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2018
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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