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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:52:38 AM


Document Has Been Signed on 07/17/2024 11:52 AM - 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: 188DATE:
07/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chris Gershtein, Vice President of Clinical Services TIME COMPLETED:
12:20 PM
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On 7/17/2024 at 10:15AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit. LPA met with Vice President of Clinical Services, Chris Gershtein and explained the reason for the visit. Executive Director Soledad Martinez was no available during the time of the visit.

LPA received a UIR regrading a resident got admitted to SNIF due to wound care. LPA interview S1, review resident files including but not limited to admission agreement, physician report, updated appraisal needs, and care note including home health care notes.

Resident is on a CCRC contract. Resident was in SNIF in 11/1/23 and graduated back to AL in 12/23/23. During that time when resident was in assisted living home health was assisting resident with wound care. During the time resident wound was at a stage between one and two. This resident has been back and forth with SNIF and RCFE multiple times. This resident has home health that assisting him during the whole duration of the time. LPA interview S1 indicate that this resident was refusing care because he very independent and doesn’t want help from anyone. That’s the reason why he back and forth between assisted and SNIF. According to S1 resident is doing better but is still in SNIF due to his care for wound. Resident wants to be back to assisted living, but S1 indicated he did not pass his room safety check. That’s the routine that facility does for any resident want can be potential to graduate from SNIF. Resident is doing better and is still in SNIF.


No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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