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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:01:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MASONIC HOMES FOR ADULTSFACILITY NUMBER:
191592287
ADMINISTRATOR:JUDY FIGUEROAFACILITY TYPE:
741
ADDRESS:1650 EAST OLD BADILLO STTELEPHONE:
(626) 251-2200
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:112CENSUS: 58DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Sandy Fahey, Director of residential Services
Maria Vasquez, LVN		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Director of Resident Services, Sandy Fahey, and Maria Vasquez, LVN, both assisted with visit. The facility is licensed to serve one hundred & twelve (112) Non-Ambulatory residents (ages 60 and above). The facility has an approved Hospice Waiver for five (5) residents on file. No residents are on hospice.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility has 3 buildings and 56 resident rooms. Resident rooms consisted of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. LPA visited resident room #A113, A112, B113, and C113. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature is in a range of 106.5 to 112.4 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies in stock.

The facility consist of several Administrative offices, a reception area, beauty salon, wellness center, 3 libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, game room, painting/card making room, general store, housekeeping storage room, dental office, computer lab, nurses station, bingo room, exam room, staff lounge and recovery room. There are multiple storage closets/rooms and an indoor/outdoor activity area. (- continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MASONIC HOMES FOR ADULTS
FACILITY NUMBER: 191592287
VISIT DATE: 05/21/2021
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Fifteen (15) public restrooms are available which are clean and operational. There are four (4) residential laundry rooms and a maintenance laundry room. Sufficient supply of perishable and nonperishable foods. Smoke and carbon monoxide detectors are operable. They are monitored by a Fire Alarm company. The facility has total of 85 fire extinguishers and LPA checked 6 of them. They are fully charged and last service was on June 16, 2020.

The first aid kit is fully stocked with manual. All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Medications are centrally, stored and locked and records are current. Fire/ Emergency drill conducted on May 11, 2021. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to resident rooms within seconds. Administrator certificate is current with expiration day on 01/09/2022.



Exit conference was conducted. A copy of LIC 809s was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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