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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:00:55 AM


Document Has Been Signed on 06/14/2022 11:00 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, 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: 60DATE:
06/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sandra Fahey- AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Maldonado conducted an unannounced visit to the above mentioned facility. The reason for the visit was to reissue a citation that was issued on 06/10/2022 and will reflect the correct regulation under which it will be cited. The citation will remain unchanged.
LPA Maldonado met with Administrator Sandra Fahey today, and explained the reason for the visit.

During the 06/10/2022 visit, LPA Maldonado obtained a copy of the resident and staff roster. While reviewing file for Staff #1 (S1), it was discovered that S1 had been employed at the facility since 04/18/2016 and had a criminal record clearance, but was not associated to the facility. S1 was associated on 06/09/2022.
Administrator stated that S1 was initially associated to the wrong facility.

California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.
Immediate Civil Penalties in the amount of $500 were issued on today's visit.

The report and appeal rights were discussed with the administrator and a copy of each were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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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Document Has Been Signed on 06/14/2022 11:00 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/14/2022
Section Cited

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by:
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Cleared on 06/09/2022.
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During S1's file review, it was discovered that S1 was cleared and not associated to facility since employment on 04/18/2016. S1 was assciated on 06/09/2022, which posed an immediate Health and Safety risk to clients in care. Civil Penalties were assessed in the amount of $500.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/14/2022 11:00 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2022
Section Cited

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by:
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Cleared on 06/09/2022.
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During S1's file review, it was discovered that S1 was cleared and not associated to facility since employment on 04/18/2016. S1 was assciated on 06/09/2022, which posed an immediate Health and Safety risk to clients in care. Civil Penalties were assessed in the amount of $500.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3