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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 03/06/2023
Date Signed: 03/06/2023 06:56:25 PM


Document Has Been Signed on 03/06/2023 06:56 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: 87DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Soledad MartinezTIME COMPLETED:
07:15 PM
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On this day at around 9:15 am, Licensing Program Analysts (LPAs) Lizette Francisco and Luisa Fontanilla conducted an unannounced 1 Year Required Inspection. Upon arrival at the Pavilion Building, LPAs met with Licensed Nurse (LVN) Princess Chan and explained the reason of the visit. Soledad Martinez, Executive Director arrived at around 9:45 am. The Pavilion is a two storey building with 2 residents in Memory Care Unit on the first level and 8 Assisted Living residents on the upper level.

LPAs toured facility with LVN including but not limited to bedrooms, bathrooms, kitchen and common areas. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ bathrooms was measured at 105.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. Fire extinguishers were last purchased on 3/11/2022. First aid kit was observed to be complete. LPAs reviewed five resident records and 5 staff records. All staff are fingerprint cleared and have current first aid training.

At around 4:30 pm, LPAs inspected the Wollenberg Building which has 8 Memory Care residents. Five residents and 5 staff were interviewed. LPAs reviewed 5 staff and 5 resident files.

LPAs will return to continue inspection at a later time.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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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