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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603161
Report Date: 06/22/2021
Date Signed: 06/22/2021 04:01:56 PM

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:CALIFORNIA MISSION INNFACILITY NUMBER:
198603161
ADMINISTRATOR:KATHLEEN OLSONFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 44DATE:
06/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Tyler Cheney, Operations DirectorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted a Case Management-Deficiencies visit due to information obtained during complaint control #: 28-AS-20210105160055 visit. LPA met with Business Director Haigaz Kazazian and explained the purpose of the visit.

On 12/26/2020, resident (R1) fell in the Memory Care Unit TV room and sustained an injury in the face/eye area. The facility failed to report the incident within reporting requirements time frame. In addition, during the course of the complaint investigation LPA requested a copy of the incident report but it was never provided. Per current administration staff the incident report was given to former Administrator Lori Waters, but it was not submitted to Community Care Licensing.



Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(1) "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...."

Deficiencies are cited in LIC 809D.

Exit interview conducted with Business Director Haigaz Kazazian. Appeal Rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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: CALIFORNIA MISSION INN
FACILITY NUMBER: 198603161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited

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87211(a)(1). Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Based on record review and interviews conducted the facility failed to report a fall incident involving resident (R1). The incident occurred on 12/26/2020. The facility did not submit the incident report to Licensing or furnish a copy when requested for complaint control #: 28-AS-20210105160055. This poses a potential health and safety risk to residents in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021
LIC809 (FAS) - (06/04)
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