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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:52:37 PM

Substantiated


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
01/24/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250124155256
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: 35DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Maria Roleda, Clinical SupervisorTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Staff do not respond to resident's call for assistance in a timely manner
Staff do not ensure that resident's toileting needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit to investigate the above allegations. LPA met with Maria Roleda, Clinical Supervisor and discussed the purpose of the visit.

The investigation consisted of: LPA took tour of common areas, interviewed five (5) staff (S#1-S#5), five (5) residents (R#1-R#5), reviewed and obtained staff and residents rosters, R1 skilled nursing facility (SNF) discharge orders, R1 admission agreement, R1 move in record, R1 SNF follow up note dated 11/18/2024, Calstro Hospice progress notes dated 01/06/2025, Pointclickcare notes from 11/29/2024 – 01/26/2025, MedChoice LA Home Health Care Inc. dated 11/29/2024, R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 11/26/2024, Calstro Hospice admission documentation dated 12/27/2024, R1 medication list, R1 Special Diet Clarification form dated 11/26/2024. DHCS Individual Service Plan – Assisted Living Waiver. Facility food menu. Call light record for month of December 2024.
(Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 5
Control Number 28-AS-20250124155256
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2025
Section Cited
CCR
87411(a)
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Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance...

This requirement is not met as evidenced by:
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The Administrator will provide an in-service training to all staff on Personnel Requirements and ensure that all staff are adhering to the residents call light request. Provide the in service sign in sheet with staff signatures and topics discussed by POC due date 02/06/2025
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Statements from staff and residents in care, revealed that staff are not responding to the call light assistance within a reasonable time frame which poses a potential health and safety risk to residents in care.
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Type B
02/06/2025
Section Cited
CCR
87625(a)(1)(c)
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Managed Incontinence. The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:
(1) The condition can be managed with any of the following: A program of scheduled toileting at regular intervals.

This requirement was not met evidenced by:
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The Administrator will review Title 22 Regulations, Section 87625 on Managed Incontinence and conduct an in-service training with all staff and provide a copy of the sign in sheet of all attendees along with the topics covered during the in-service training. POC is due to CCL by 02/06/2025
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Statement obtained from staff and resident stated R1 was left in soiled diaper for unreasonable time.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250124155256
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: 01/30/2025
NARRATIVE
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The investigation revealed:

Allegation: Staff do not respond to resident's call for assistance in a timely manner. It is alleged that facility staff take too long after pendant is push for assistance.

LPA Interviewed five (5) staff and four (4) of five (5) staff denied the allegations. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. LPA interviewed five (5) residents and two (2) of five (5) residents stated that facility staff sometimes take a long time to assist them. LPA reviewed call light log, and, on at least 4 different occasions, it did take over 60 minutes for staff to assist residents during the month of December 2024. There is enough evidence to substantiate this allegation.

Allegation: Staff do not ensure that resident's toileting needs are met. It is alleged that resident was left in his bodily fluids after bowel and bladder movement and developed a rash due to staff neglect.

LPA interviewed five (5) staff and four (4) of five (5) staff denied the allegations. LPA interviewed five (5) residents and four (4) of five (5) residents were not able to corroborate the allegation. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. Some staff stated R1 had rash when R1 arrived to facility. There is enough evidence to substantiate this allegation.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 02. See LIC 9099D.

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

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/24/2025 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20250124155256

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: 35DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Maria Roleda, Clinical SupervisorTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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9
Resident sustained a pressure ulcer due to staff neglect
Staff do not follow resident's special diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit to investigate the above allegations. LPA met with Maria Roleda, Clinical supervisor and discussed the purpose of the visit.

The investigation consisted of: LPA took tour of common areas, interviewed five (5) staff (S#1-S#5), five (5) residents (R#1-R#5), reviewed and obtained staff and residents rosters, R1 skilled nursing facility (SNF) discharge orders, R1 admission agreement, R1 move in record, R1 SNF follow up note dated 11/18/2024, Calstro Hospice progress notes dated 01/06/2025, Pointclickcare notes from 11/29/2024 – 01/26/2025, MedChoice LA Home Health Care Inc. dated 11/29/2024, R1 Physician's Report for Residential care Facilities for the Elderly (RCFE) dated 11/26/2024, Calstro Hospice admission documentation dated 12/27/2024, R1 medication list, R1 Special Diet Clarification form dated 11/26/2024. DHCS Individual Service Plan – Assisted Living Waiver. Facility food menu. Call light record for month of December 2024.

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

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250124155256
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: 01/30/2025
NARRATIVE
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The Investigation revealed:

Allegation: Resident sustained a pressure ulcer due to staff neglect. It is alleged that resident developed a pressure ulcer due to neglect of facility.

LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of five (5) residents cold not corroborate the allegation. R1 was admitted to facility on 11/27/2024 with ulcer on right foot and admitted to Home Health agency on 11/29/2024 to provide wound care. Documentation shows R1 had pressure ulcer(s) as far back as 11/18/2024 while residing at SNF. R1 was admitted to Hospice on 12/23/2024 and documents from Hospice show R1 had stage 2 and stage 3 ulcers. R1 has history of skin breakdown when admitted. Facility addressed the issue right away by ordering wound care for resident through home health agency. There is not enough evidence to support this allegation.

Allegation: Staff do not follow resident's special diet. It is alleged that resident was on special diet and facility did not honor it by feeding R1 pasta, pastries, pizza and food that R1 is not supposed to eat.

LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of (5) residents were not able to corroborate the allegation. LPA reviewed doctor’s orders for R1 and it showed that R1 was regular diet with no dietary restrictions. Other special needs were documented as no salt added (NAS) thin liquid. Two (2) residents stated that the food does not have salt and that they must add salt to their taste. Staff stated that food is cooked with NAS as many residents cannot have salt in their diets.

Based upon records review, and interviews conducted, the findings indicate that, 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 with Maria Roleda, Clinical Supervisor. A copy of the report was provided. .
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5