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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 03/17/2026
Date Signed: 03/17/2026 04:48:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/13/2026 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260313164816
FACILITY NAME:CALIFORNIA MISSION INNFACILITY NUMBER:
198603161
ADMINISTRATOR:JARED GREENFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 62DATE:
03/17/2026
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:TIME COMPLETED:
04:59 PM
ALLEGATION(S):
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Staff are not meeting resident's showering needs
Staff did not ensure resident's room was free of odors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Chief Operating Officer Heather Cummings and discussed the purpose of the visit.

The investigation consisted of LPA reviewing and obtaining copy staff and resident rosters of R1 admission agreement, needs and appraisal, physician’s report, bathing log, taking tour of R1 room,and other random rooms, interviewing Six (6) staff and seven (7) residents.

The investigation revealed regarding allegation: Staff are not meeting resident's showering needs. It is alleged that facility staff is not providing bathing services to resident as required. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed seven (7) residents and all seven (7) could not corroborate the allegation.

(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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-20260313164816
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MISSION INN
FACILITY NUMBER: 198603161
VISIT DATE: 03/17/2026
NARRATIVE
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(continued from 9099C)

Facility records show that resident was admitted to facility on 02/06/2026 and was provided with bathing services on the following dates 02/10/2026 02/12/206, 02/17/2026, 02/19/2026, 02/24/2026, 02/26/2026, 03/03/2026, 03/05/2026, 03/10/2026, 03/12/2026, and 03/17/2026 Resident stated resident refused to bathe one time. Date is unknown. LPA observed resident to be clean, groomed and in clean clothes. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not ensure resident's room was free of odors. It is alleged that room has urine odor. LPA interviewed six (6) staff, and all six staff denied the allegation. One staff member stated that there was a urine smell in resident’s room a while back, but it had been addressed immediately. LPA interviewed seven (7) residents, and all seven (7) residents could not corroborate the allegation. LPA inspected resident’s room and another six random rooms and did not notice any kind of foul smell in any of the rooms.

Based upon records review, interviews conducted, and observations, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted, and copy of the report was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2