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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440129
Report Date: 11/20/2019
Date Signed: 11/20/2019 03:31:26 PM



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
11/19/2019 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20191119183144
FACILITY NAME:MASONIC HOME FOR ADULTSFACILITY NUMBER:
011440129
ADMINISTRATOR:JOSEPH PRITCHARDFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 471-3434
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:242CENSUS: 232DATE:
11/20/2019
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joseph PritchardTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was hospitalized due to lack of care by staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegation and met with Joseph Pritchard.

LPA interviewed Administrator and reviewed Resident 1 (R1) records as follows: admission notes and hospital discharge. Based on admission records, R1 was admitted to the facility's skilled nursing facility on 1/13/2017 from an acute rehabilitation facility in Carmichael, CA. Administrator confirmed with LPA that R1 was never a resident in the assisted living part of the community. He added that R1 moved in directly to the facility's skilled nursing from 2017 to present. The Department does not have jurisdiction on skilled nursing facilities. Based on interview and records reviewed, the above allegation is unfounded.

This agency has investigated the complaint. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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