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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:48:56 PM


Document Has Been Signed on 01/09/2024 03:48 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: 210DATE:
01/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Soledad Martinez, AdministratorTIME COMPLETED:
03:55 PM
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On 1/09/24 at 2:00 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of an email sent to CCL regarding a boiler in one of the facility's buildings being inoperable resulting in no heat in the residents apartments. LPA met with Administrator, Soledad Martinez and explained the purpose of the visit.

LPA toured facility including but not limited to 3 apartments, hallway and common areas. LPA also interviewed S1 and 3 residents (R1, R2 and R3). The building without heat is part of the facility's independent living residences.

S1 stated that the boiler in still down in the South Building. A replacement part has been ordered and is expected in 3 weeks time at which time the unit will be repaired. S1 further stated that she has keep in communication with the residents in the South Building via memos and has offered them all space heaters and extra blankets. Only 14 of the 36 residents in the building have requested space heaters.

LPA interviewed R1 who has a space heater but is not using it. R1 also stated that he feels that the staff at the facility are doing a "great job" keeping the residents informed of the issues with repairs.

R2 stated that he has a space heater but only uses it during the daytime hours. R2 also stated that he feels that the staff are keeping the residents informed of the issues with repairs.

R3 stated that she has a heater but only used it during the day. R3 thinks the staff are "doing their very best" in dealing with this issue.

LPA requested proof of the completed repair work be sent to him via email and documentation that the unit is now functional.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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