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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 10/31/2024
Date Signed: 10/31/2024 10:57:43 AM

Document Has Been Signed on 10/31/2024 10:57 AM - 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/
DIRECTOR:		SOLEDAD MARTINEZFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 471-3434
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 242TOTAL ENROLLED CHILDREN: 0CENSUS: 217DATE:
10/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Soledad Martinez, Excutive Director TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 10/31/2024 at 9:15AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit. LPA met with Executive Director (ED), Soledad Martinez and explained the reason for the visit.

LPA received a SOC 341 regrading a self-reporting from R1 stated R1didn’t want to stay at the facility. R1 stated R1 was placed at the facility without knowing. Previously R1 resided at Clear Water in Southern California. R1 have a POA (friend) that is 75-year-old. LPA interview R1 regrading the SOC 341 received on 10/28/24. R1 stated R1 feel bored at the facility and missed R1 friend a lot. R1 felt abandon by R1 friend, and just want to stay with R1 friend in Southern California at R1 previous facility. R1 stated “feel safe, staff are not mis-treating R1, but they are boring”. When asked R1 knows that R1 is residing at Masonic, but just want to go back to Southern California. During the interviewed session LPA observed that R1 forgets what R1 was saying, and repeats alot. R1 physician report states R1 diagnose with dementia/ short term memory. According to ED R1 previous facility do not have a memory care unit, also R1 does not like Clear Water, and that's the reason why R1 is placed here by POA. LPA reviewed R1 files including but not limited to physician report, ID notes, and Health Care POA.

No citation issue on today date.

Exit interview is conducted and a copy of this report is provided to ED.

Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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