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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:02:38 PM


Document Has Been Signed on 07/28/2022 04:02 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: 152DATE:
07/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Soledad Martinez, Executive Director TIME COMPLETED:
04:15 PM
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On 7/28/2022 at 3:30PM , Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management visit. LPA met with Executive Director Soledad Martinez, and explained the reason for the visit.

LPA went to the facility to deliver an immediate exclusion letter and verified that S1 was no longer working at the facility. LPA delivered letter to Soledad Martinez. LPA confirmed that S1 was not at the facility.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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