191592287-5-20-2024-28-AS-BTAO-D5FVSG-20240520164132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 05/20/2024
Date Signed: 05/20/2024 04:41:40 PM

Document Has Been Signed on 05/20/2024 04:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MASONIC HOMES FOR ADULTS		FACILITY NUMBER:	191592287
ADMINISTRATOR:	VINCENT L. GONZAGA		FACILITY TYPE:	741
ADDRESS:	1650 EAST OLD BADILLO ST		TELEPHONE:	(626) 251-2200
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	112	CENSUS: 57	DATE:	05/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:	Anabel Mejia, Executive Assistant		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Anabel Mejia, Executive Assistant 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 09/12/25. Annual fees were current. During the visit, Care Tool, physical plant, staff/residents interviews, file reviews, medication review, food supply review were conducted. The facility locates at 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. There are multiple storage closets/rooms and an indoor/ outdoor activity area. The facility has fifteen (15) public restrooms, four (4) residential laundry rooms and a maintenance laundry room. Resident rooms consists 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 is in a range of 110.7 to 115.5 degrees Fahrenheit. Adequate linen and personal hygiene supplies are in stock. Sufficient supply of perishable and nonperishable foods were observed. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

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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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: 05/20/2024

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Smoke / carbon monoxide detectors are operable and monitored by a fire alarm company. Elevators and signal system are operable which are available for residents' use. No bodily of water are observed in the facility. Swimming pool at the yard, pond at patio and jacuzzi at the first floor are empty with no water. They are locked, inaccessible to residents and surrounded with a 6-ft high fence. Medications are centrally, stored and locked and records are current. Fire/ Emergency drill conducted on April 2024 (every quarter). All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris.

An exit conference was conducted. A copy of LIC 809s were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

LIC809 (FAS) - (06/04)

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