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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 08/13/2026
Date Signed: 08/13/2026 03:27:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/05/2026 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260805151112
FACILITY NAME:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:JARED GREENFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 73DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maria Roleda, Clinical DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee does not ensure there are adequate staff to meet resident's needs.
Staff does not ensure the residents rooms are clean and sanitary.
Facility is not free of pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with Administrator Jared Green. The purpose of the visit was explained.

LPA obtained copies of the staff and resident rosters, selected (8) rooms to inspect, and conducted interviews with Staff and Residents.

The investigation revealed the following:
Allegation - Licensee does not ensure there are adequate staff to meet resident's needs. LPA interviewed seven (7) staff, and all of them feel there is sufficient staff at the facility. The facility employs (3) caregivers in the morning shift, (2) in the afternoon shift, and (1) in the overnight shift. There is at least one (1) med tech on each shift who can assist the caregivers if needed during their shifts.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
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 2
Control Number 28-AS-20260805151112
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MISSION INN - ROSE MANOR
FACILITY NUMBER: 198603163
VISIT DATE: 08/13/2026
NARRATIVE
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 Staff stated they provide showers, escort to meals, change those who are incontinence, and take out the trash. LPA interviewed eight (8) residents. Seven (7) out of the eight (8) feel there is sufficient staffing to meet their needs. The residents interviewed today mainly need assistance with showers, escorting, and toileting. Residents stated that the staff check on them often and will respond to the call button timely. Based on information gathered, there is insufficient evidence to corroborate this allegation.

Allegation - Staff does not ensure the resident rooms are clean and sanitary. LPA interviewed seven (7) staff who stated that the resident rooms are cleaned at least once a week by the housekeepers. Care staff also assist with ensuring the rooms are clean and sanitary by taking out the trash after incontinence changes. If staff observe the room needs extra cleaning, they will inform the housekeeper who will do it. Staff stated they do not deny requests if the room needs to be cleaned again. LPA interviewed eight (8) residents. Seven (7) out of the eight (8) stated that the housekeeper cleans their rooms once a week and do not have any issues about their rooms not getting properly cleaned.

Allegation - Facility is not free of pests. LPA selected eight (8) resident rooms to inspect during the visit today. The rooms appeared clean and sanitary. There were no bugs or roaches observed in the rooms or in the interior of the facility. LPA obtained and reviewed copies of the pest control service reports for the past (3) months. The facility is receiving services for roaches and rodent repellent. Staff interviews revealed that the facility receives pest control services frequently, and if they observe any pests, they inform the maintenance staff right away to address the concern. Six (6) out of the eight (8) residents interviewed have not seen roaches in their rooms. One (1) saw roaches a few months ago, and another saw some flies and roaches recently in the room. Based on information gathered, the facility is taking proactive measures to prevent pests and treat the areas/rooms where pests are observed.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Staff M. Roleda. A copy of this report, along with the appeal rights, was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2