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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:19:03 PM


Document Has Been Signed on 02/28/2024 04:19 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: 167DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Soledad Martinez, Excutive DirectorTIME COMPLETED:
04:35 PM
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At around 9:00am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with Executive Director, Soledad Martinez. This facility is a Continuing Care Retirement Community (CCRC). The facility provides independent, assisted living and memory care.

LPA with Soledad inspected the following: total of 8 rooms in independent living, assisted living and memory care, kitchen, dining area, activity room and other common areas. All showers/bathrooms were observed with grab bars and non-skid floors. Multiple fire extinguishers were observed in different locations that appear full and were inspected on 1/23/2024. LPA observed sufficient supply of perishable and non perishable foods. Hot water temperature measured at 118 degrees Fahrenheit in different rooms checked. Memory Care unit has a delayed egress system that was observed functional. Maintenance log for facility generator indicates last weekly inspection was conducted on 2/27/2024 and last monthly test was done on 2/27/2024. Facility has a current disaster plan and supplemental emergency disaster plan dated 1/08/2024. First aid kit was observed complete. Last disaster drill was conducted on 2/21/2024 and 2/23/2024 (lasted two days).

LPA inspected the Wollenberg Building which has 20 Memory Care residents, and Pavillion Building which consist of 4 Memory care residents. Five residents and 4 staff were interviewed. LPA reviewed 4 staff and 8 resident files.

LPA reviewed 4 staff files 4 out of 4 staffs have health clearance on files.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection.

Exit interview conducted and a copy of this report provided via email to Executive Director.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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