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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 04/20/2026
Date Signed: 04/20/2026 02:35:01 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
04/14/2026 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260414112657
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: 46DATE:
04/20/2026
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Chief Operating Officer Heather CummingsTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff do not assist resident with showering
Resident sustained dermatitis due to staff neglect
Facility is operating out of ratio
Staff do not provide residents with adequate clothing
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 taking tour of facility, reviewing and obtaining staff and resident rosters, interviewing four (4) staff S#1 – S#4, five (5) residents R#1 – R#5 and obtaining bathing schedule for facility.

The investigation revealed regarding allegation: Staff do not assist resident with showering. It is alleged that facility is not providing bathing services to a resident (name not provided) LPA interviewed four (4) staff and all four (4) staff denied the allegation. LPA interviewed five (5) residents and four (4) of five residents could not corroborate the allegation. LPA reviewed the shower schedule, and residents are provided with bathing services twice a week or more if required. There is insufficient evidence to support this allegation.
(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
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-20260414112657
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: 04/20/2026
NARRATIVE
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(continued on 9099C)

Resident sustained dermatitis due to staff neglect. It is alleged that a resident (name not provided) obtained dermatitis due to not having hair washed. LPA interviewed four (4) staff, and all four (4) staff denied any resident having dermatitis. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several staff stated that no resident currently has dermatitis at the facility. There is insufficient evidence to support this allegation.

Facility is operating out of ratio. It is alleged that facility is operating out of ratio because resident (name not provided) is not being assisted out of bed. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. The caregivers interviewed all stated they can meet the resident’s needs. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several residents stated there is enough staff to meet resident's needs. There is insufficient evidence to support this allegation.

Staff do not provide residents with adequate clothing. It is alleged that facility is not providing residents with clothing due to resident (name not provided) being in the same clothes for five (5) straight days. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. All four (4) staff stated they have not seen any resident in the same clothes for 5 days. The caregivers interviewed all stated that facility has a donation closet that provides clients clothing for free if they are in need, LPA interviewed five (5) residents and all five (5) could not corroborate the allegation. There is insufficient evidence to support this allegation.

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: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2