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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603161
Report Date: 10/31/2022
Date Signed: 10/31/2022 04:07:09 PM


Document Has Been Signed on 10/31/2022 04:07 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:TYLER CHENEYFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 40DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Ruby Racca-Magao, Wellness DirectorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with the Wellness Director, Ruby Racca-Magao and the purpose of the visit was explained. 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 13 residents in memory care and 27 in assisted living.

LPA toured the facility and observed the following:
* The facility consists of 2 floors and a memory care unit on the 2nd floor. There are resident rooms on both floors, along with common areas, and communal bathrooms. There is a chapel room in which it is utilized by both California Mission Inn and California Mission Inn Rose Manor facilities.
* Signage are posted throughout the facility. They consist of proper wearing of the masks, sneezing etiquettes, and COVID-19 symptoms checks.
* Receptionist screens and take the temperature of visitors and staff upon arrival.
* Sufficient amount of PPE supplies of at least 30 days were observed in the storage area located in the first floor. Disinfectants and cleaning supplies are stored and locked in the housekeeping area.
* Sufficient food supplies of 2 day perishable and a week of non-perishable items are observed. Food items are restocked every Tuesday and Friday.
* LPA observed all the staff wearing a face masks.
* LPA conducted interviews with 5 staff and 4 residents.
* The medication were reviewed for 5 residents and the medications are being administered as prescribed.

No deficiencies were issued today. An exit interview was held. A copy of this report and appeal rights were given to the Wellness Director.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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