198603163-9-20-2025-28-AS-LHIS-DLRVXM-20250922164947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 09/20/2025
Date Signed: 09/20/2025 11:20:22 AM

Unsubstantiated

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
09/12/2025 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250912113820

FACILITY NAME:	CALIFORNIA MISSION INN - ROSE MANOR		FACILITY NUMBER:	198603163
ADMINISTRATOR:	JARED GREEN		FACILITY TYPE:	740
ADDRESS:	4825 EARLE AVE		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 49	DATE:	09/20/2025
		UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Hayden Petrovick, Marketing Director		TIME COMPLETED:	11:21 AM

ALLEGATION(S):

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Staff does not ensure facility elevator is in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to the facility to deliver findings for allegation above. LPA met with Hayden Petrovick, Marketing Dirctor and discussed the purpose of the visit.

09/17/2025 LPA interviewed Administrator - S#5 via phone.

09/15/2025 - The investigation consisted of LPA taking a tour of facility and testing the two (2) elevators in the Rose Manor section of facility, interviewing four (4) staff (S#1-S#4) and four (4) residents (R#1– R#4), reviewed of elevator repair invoices dated 05/01/2025, 07/24/2025, 08/01/2025, 09/10/2025, and 09/11/2025

The investigation revealed: Allegation: Staff does not ensure facility elevator is in good repair. It is alleged that staff are not addressing the constant disrepair of elevators for at least four (4) weeks

(continued on 9009C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250912113820

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 - ROSE MANOR	FACILITY NUMBER: 198603163
	VISIT DATE: 09/20/2025

NARRATIVE

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(continued from 9099)

LPA interviewed five (5) staff members, and all five (5) staff members corroborated the allegation. All five (5) staff members stated that the elevators being in disrepair has been an ongoing issue for several weeks now. Facility maintenance man stated that the elevator repair company has been called several times recently and repairs the elevator. One staff stated that some residents force the door to stay open so that residents can board the elevator and that causes the elevator to break down. LPA interviewed four (4) residents, and all four (4) residents corroborated the allegation and stated that it is an inconvenience. LPA reviewed and obtained several invoices from Next Level Elevator for maintenance on the elevators dated 05/01/2025, 07/24/2025, 08/01/2025, 09/10/2025, and 09/11/2025. The administrator stated they will discontinue using Next Level Elevator and seek another elevator repair company that can provide better results. During the visit on 09/15/2025, LPA observed the repair technician from Next Level Elevator and the technician was able to repair the elevator during the visit, as LPA was leaving the facility, LPA tested the elevator once again and the issue of the door not closing returned. The invoices from Next Level Elevator are evidence that the facility is addressing the issue of the elevators in disrepair. The elevators being in disrepair is not a fire hazard as the fire department recommends not using the elevators in case of fire. There is not enough supportive evidence to show that the facility is not addressing the elevators in disrepair.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2025

LIC9099 (FAS) - (06/04)

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