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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603161
Report Date: 10/20/2021
Date Signed: 10/20/2021 04:43:57 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:TYLER CHENEYFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 42DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Tyler Cheney, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Tyler Cheney and Wellness Director Ruby Magao and explained the purpose of the visit. The facility is a 2 story story building located in a residential neighborhood that is licensed for 85 adults 60 and over approved for 85 non-ambulatory, of which 9 may be bedridden. The facility has a hospice waiver for 20. The facility consists of a Memory Care unit, 64 rooms, 2 activity rooms, 2 dining rooms, kitchen, 2 tv rooms, puzzle room, piano room, cafe room, lounge, library, administration offices, laundry room, 2nd floor terrace area, and an outdoor water fountain. The last fire drill was conducted on 10/2/2021.

The following were observed/inspected:
  • Entrance screening, sign-in sheet, contact-less thermometer, and hand sanitizer in the main entrance is in place. COVID-19 Infection Control Practices and signs were observed in the entrance area. Not all common area hallways and 2nd floor public bathrooms did not have required postings.
  • The interior and exterior physical plant was inspected. Twenty nine (23) rooms were inspected.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • All staff were observed wearing mask. Dementia residents were not observed to be wearing masks. Non-Dementia residents were wearing masks.
  • Six (6) centrally stored resident medication records were reviewed.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Facility has sufficient supply of Personal Protective Equipment (PPEs).
  • LPA requested a copy of the staff roster and resident roster.

Deficiency was cited. See LIC 809D.
Exit interview was conducted with Administrator Tyler Cheney and Wellness Director Ruby Magao. A copy of the report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.50(a)(3)
Suspension and Revocation
(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that signs were not observed posted in all public bathrooms and hallways that promote handwashing, cough/sneeze etiquette, and physical distancing. Four (4) out of 23 resident rooms inspected did not have either hand sanitizer or hand soap in the rooms. In addition, the latest Provider Information Notice (PIN) 21-44 was not posted where persons in care can easily access it and distribute the PIN Summary for Persons in Care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2021
Plan of Correction
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Administrator agreed to post infection control signs in all bathrooms, common area bathrooms & hallways, as well as ensure that hand sanitizer and soap are available for all residents in care. The latest PINs shall be posted in an easily accessible location.

Submit a written statement stating how the deficiency was corrected. Attach picture proof of common area/public bathroom postings.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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