<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603161
Report Date: 10/19/2023
Date Signed: 10/19/2023 03:26:21 PM


Document Has Been Signed on 10/19/2023 03:26 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:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Ruby Racca-MagaoTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 10/19/2023 at 11:03 am. 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.

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.
* 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. Water temperature in kitchen sink was measured at 136 degrees F. LPA Ramirez will issue Technical Violation.

* LPA Ramirez selected the following rooms at random to inspect: 128, 130, 154, 155, 254, 257, and 276. All resident rooms contained required linens, lighting and furniture.

* Dining room area was observed to be clean and contained multiple tables with plenty of seating.

* LPA observed medication room to be locked and inaccessible to residents in care.

Due to time constraints, LPA will return to complete annual inspection.

No deficiencies were issued today. An exit interview was held. A copy of this report, LIC 9102 and appeal rights were given to the Wellness Director.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2