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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592287
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:00:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2020 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201105113734
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: 56DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator- Sandra FaheyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
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9
Staff threatened physical harm to resident
INVESTIGATION FINDINGS:
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2
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5
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9
10
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13
Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced complaint visit to investigate the above allegation. LPA met with Administrator Sandra Fahey and explained the reason for the visit.

On 11/12/22, LPA Long conducted an interview telephonically with Staff #1 (S1) and requested a copy of the Staff/Resident Roster.

On 7/20/22 LPA Calderon conducted an investigation and it consisted of the following: LPA Calderon interviewed residents #2 - #11(R2 - R11) and interviewed staff #1-#10 (S1-S10).

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
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 28-AS-20201105113734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/20/2022
NARRATIVE
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In regards to the allegation "Staff threatened physical harm to resident" it was alleged that S2 threatened R1 by demonstrating how S2 would kick him. (10) of (10) residents stated they are not aware of any residents being threatened by staff and staff treat them okay, great, friendly, nice and respectful. (10) of (10) staff stated they are not aware of any residents who were threatened . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2