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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 05/28/2026
Date Signed: 06/03/2026 03:31:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/03/2026 03:31 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MASONIC HOMES FOR ADULTSFACILITY NUMBER:
191592287
ADMINISTRATOR/
DIRECTOR:		VINCENT L. GONZAGAFACILITY TYPE:
741
ADDRESS:1650 EAST OLD BADILLO STTELEPHONE:
(626) 251-2200
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 112CENSUS: 57DATE:
05/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Executive Assistant Anabel MejiaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Sanjay Vaid conducted an unannounced annual inspection visit. LPA met with Anabel Mejia Executive Assistant and George Diaz, Director of Facility Services who assisted with the visit. The facility was licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility had an approved five (5) hospice waivers. Administrator certificate was current with expiration date on 09/12/2027. Currently there are 57 residents. Zero (0) dementia and zero(0) hospice residents on campus.

During the visit, Care Tool was utilized as follows,

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and have an infection Control Plan at facility.
Operational Requirements: The facility does accept patients with dementia. There zero (0) bedridden residents residing at the facility. The facility has sufficient liability insurance covering injury to residents and guest. Liability insurance expires 04/01/2027.
Physical Plant & Environment Safety: The facility is in a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident apartments. The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, three (3) libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, activity /game room/painting/card making room, general store, housekeeping storage room, computer lab, nurses station, bingo room, exam room, staff lounge, and recovery room.
CONTINUED ON 809C......................
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MASONIC HOMES FOR ADULTS
FACILITY NUMBER: 191592287
VISIT DATE: 05/28/2026
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CONTINUED FROM 809

There are multiple storage closets/rooms and an indoor/ outdoor activity area. The facility has four (4) residential laundry rooms and a maintenance laundry room. Resident rooms consist of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature was in a range of 105.7 to 117.3 degrees Fahrenheit which is within range of 105.0 -120.0 degrees F. Adequate linen and personal hygiene supplies are in stock.

Staffing: There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Admission Agreements and Physicians reports. Random five residents files were observed.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Monthly activity calendar and daily activity flyers are handed to residents daily.
Food Service: There are sufficient food supplies of 2-day perishable and 7 day non perishable food. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 5 residents' medication, and the medication is administered according to doctor’s orders. Six (6) residents are currently on oxygen administration.
Disaster Preparedness: The facility has an Emergency Disaster Plan. Safety drills are conducted twice per year, last drill was conducted 10/16/2025.
Residents with Special Health Needs: There are no residents with special health needs at facility.

Zero (0) Deficiencies noted on today’s visit. Exit interview conducted with Anabel Mejia and copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
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