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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:12:18 PM


Document Has Been Signed on 01/18/2023 12:12 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: 156DATE:
01/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Soledad Martinez, AdministratorTIME COMPLETED:
12:30 PM
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On 1/18/2023 starting at 11:20 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a Case Management visit to follow-up on facility renovation in the Wollenberg building. Fire clearance was approved on 12/20/2022. LPA met with Executive Director, Soledad Martinez and explained the purpose of the visit. Fire clearance was approved all non-ambulatory residents. The building currently has no residents occupying the floor.

During the Case Management visit, LPA toured facility including but not limited to dining room area, activity room, medication room, laundry room, and random resident rooms. LPA observed smoke detector, carbon monoxide detector and sprinklers throughout facility. Hot water temperature was maintained at 109.7 degrees F. Fire extinguisher was last serviced on 1/10/2023. The expected move-in date for residents is scheduled at end of January/early February.

Administrator agrees to submit an invoice for water leak repair in APT 512 by 1/30/2023.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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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