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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603161
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:08:48 PM

Document Has Been Signed on 10/30/2023 02:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MISSION INNFACILITY NUMBER:
198603161
ADMINISTRATOR:DWIGHT DUNAGANFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 85CENSUS: 48DATE:
10/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ruby Racca-MagaoTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent Annual Required 1-year Visit on 10/30/2023 at 10:23 am. Initial Annual Required 1- year visit was conducted on 10/19/23. LPA was met by Wellness Director, Ruby Racca-Magao and explained the purpose of the visit. The facility is licensed for 85 non-ambulatory adults, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. There are currently 14 residents in memory care and 34 in assisted living.

LPA Ramirez reviewed ten (10) personnel records and ten (10) resident records and received a copy of facility liability insurance. Three (3) out of the ten (10) personnel records reviewed are care givers in the facility memory care unit. LPA Ramirez observed an Administrator's Certificate for Dwight Dunagan which expires 07/11/2024. LPA Ramirez did not observe and deficiencies during today's visit.

Exit interview was conducted with Administrator Dunagan. A copy of this report and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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