191592287-7-11-2023-28-AS-ACAN-CTMUGF-20230711153415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:34:25 PM

Document Has Been Signed on 07/11/2023 03:34 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: 51	DATE:	07/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:			TIME COMPLETED:	03:35 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) Ashley Calderon conducted an unannounced annual inspection visit. LPA met with Administrator Vincent Gonzaga and shortly with Donato Rodriguez / Facility Director, whom assisted with the visit. The facility is licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility has an approved five (5) hospice waivers. Currently (0) residents are on hospice. 23 Independent residents and 28 assisted living residents. During the visit, the CARE tool was used, a tour of the facility was conducted with Donato. The facility locates at a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident rooms. Food supply was reviewed sufficient perishable and non-perishable food items observed, total of 3 freezers and 3 refrigerators, thermometers in place. Separate room in kitchen for locked cleaning solutions and disinfectants. LPA Calderon alongside with LVN Jacqueline Giron reviewed Medication Record and medications for a total of 4 residents. 23 residents need assistance with medication and are stored in med room, no deficiencies were observed. Medication Room had sufficient PPE. Resident rooms consists of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. LPAs visited resident rooms #A-108, A-113, B-103, B-106, and C-102,C-106 and C_112. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature is in a range of 111.1 to 119 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are in stock in Building M1. Total of 4 laundry rooms for residents and one laundry room for staff use. (Continuation on LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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: 07/11/2023

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The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, 3 libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, ceramic room, aviation room, thrift store, activity /game room/painting/card making room, general store, housekeeping storage room, lactation 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 which are clean and operational. Smoke alarms are tested quarterly using TRL Service and Testing Company and wired to the Fire Department of Covina. Carbon monoxide detectors are operable. Fire extinguishers were located throughout the facility, extinguishers were serviced and charged. Fire Drill conducted on 7/11/23. Elevator is operable and available for residents' use. Signal systems in resident rooms are operable. Swimming pool and jacuzzi are empty with no water, locked and gated. No bodily of water are observed in the facility.

The first aid kits observed and located in Wellness Center, Kitchen, and Med Room are fully stocked with a manual. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Facility landline phone is operable for residents' use. Administrator certificate is current with expiration date of 09/12/2023 for Vincent Gonzaga. Nursing Home Administration Expiration date: August 31, 2023.

LPA Calderon review 5 resident files alongside with Executive Assistant Anabel Mejia and 5 staff files. All appropriate documentation's were filed, staff are clear and no deficiencies noted. A total of 4 residents were interviewed and 1 staff interview was conducted.

Liability insurance expires: April 1, 2024

No deficiencies were observed during today's inspection.
An exit interview was conducted. A copy of this report was provided to Vincent Gonzaga.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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