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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 09/14/2026
Date Signed: 09/14/2026 04:10:43 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/14/2026 04:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR/
DIRECTOR:		JARED GREENFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 85CENSUS: 75DATE:
09/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Vanessa Navarro, Wellness CoordinatorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit. LPA met with Vanessa Navarro, Wellness Coordinator who assisted with visit. LPA explained the reason for the visit. The facility is licensed to serve 85 non-ambulatory residents ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. The facility have a dementia care plan.

LPA and Wellness Coordinator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, activity room, storage room, Wellness Room, Med Room. The building has 5 floors. The 5th floor has the kitchen and dining room. The kitchen and dinning room were clean. The food comes from the main kitchen next door. The kitchen in this building is only used to serve food. The main kitchen was also inspected. LPA observed sufficient food supplies of 2da y perishable and a 7 day of non-perishable food. All the appliances are clean and seem to be operating properly. Sharps are locked in the kitchen and inaccessible to residents. The other 4 floors are where the residents reside. All 4 floors were toured. Each floor has a carbon monoxide detector and smoke detectors. Several fire extinguishers were observed throughout the facility. The hallways and stairways were clear and free of any obstructions. Resident rooms were randomly chosen for inspection on each floor. The rooms are properly furnished. The bathrooms have the required grab bars near the toilet and in the shower. The hot water temperature was tested randomly chosen rooms and measured within Title 22 Regulation guidelines. There is a water fountain in the courtyard which has a gate around the entire perimeter. There are no other large bodies of water on the premises. Facility has 2 elevators and they were working properly at the time of the visit. There is a shaded seating area for the residents. The common areas are clean and have the required furniture.

Continue 809C

Wei Siew Ho
Nune Margaryan
DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/14/2026 04:10 PM - It Cannot Be Edited


Created By: Nune Margaryan On 09/14/2026 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MISSION INN - ROSE MANOR
FACILITY NUMBER: 198603163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2026
Section Cited
CCR
87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
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During the visit, facility staff immediately removed the scissors, snap-off utility knife, and cleaning supplies and secured the items in locations inaccessible to residents. The Licensee/Administrator will ensure that sharp objects, cleaning supplies, and other potentially hazardous items remain inaccessible to residents at all times.The deficiency was corrected and POC was cleared during the visit.
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During the facility tour, LPA observed a pair of scissors and a snap-off utility knife stored unsecured in an unlocked cabinet drawer in the Wellness Room. LPA also observed cleaning supplies stored in an unlocked cabinet underneath the sink in the bathroom located within the Wellness Room. The Wellness Room did not have a door and was accessible to residents. The unsecured sharp objects and cleaning supplies were readily accessible to residents, which posed an immediate health and safety risk to residents in care.
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2026


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 - ROSE MANOR
FACILITY NUMBER: 198603163
VISIT DATE: 09/14/2026
NARRATIVE
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During the facility tour, LPA observed that the Wellness Room did not have a door, making the room accessible to residents. LPA observed a pair of scissors and a snap-off utility knife stored unsecured in an unlocked cabinet drawer. LPA also observed cleaning supplies stored in an unlocked cabinet under the sink in the bathroom located within the Wellness Room. The scissors, utility knife, and cleaning supplies were unsecured and accessible to residents. The first aid kits were observed and found to be in compliance with the Title 22 Regulations. LPA observed the medications are centrally stored in the Med. Room and inaccessible to residents. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. During today’s visit, LPA reviewed resident medications and they are being administered as prescribed by the physician. LPA reviewed 4 resident and 4 staff files.Last Fire drill conducted on 08/04/26.

Deficiency observed and documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided to Wellness Coordinator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026
LIC809 (FAS) - (06/04)
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