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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440129
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:10:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230628101622
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: 217DATE:
11/15/2023
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Soledad Martinez, Executive DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are abusing residents in care
Staff are mismanaging resident's medications
INVESTIGATION FINDINGS:
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On 11/15/2023 at 11:55 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit and deliver findings. LPA explained the purpose of the visit with Executive Director Soledad Martinez.

On the allegation facility staff are mismanaging resident's medications. Based on observation, record review and interviews, the facility staff will pre pour residents medications and leave them locked in the medication room. Based on interviews with staff the medications are not pre-poured over 24 hours in advance and are given to the residents the same day they are poured. The residents medication is keep separated and marked to avoid residents receiving the wrong dosage.

On the allegation facility staff are abusing residents in care. In an interview with S1they stated that S2 was rude to residents in care. R1 and R2 stated that they did have a disagreement with S1 and brought it to the

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20230628101622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ADULTS
FACILITY NUMBER: 011440129
VISIT DATE: 11/15/2023
NARRATIVE
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... Continued from LIC9099

attention of facility management. R1 and R2 state that since then all has been well and they feel that S2 work is well and better.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2