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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:45:27 PM


Document Has Been Signed on 11/04/2022 04:45 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 INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:TYLER CHENEYFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 40DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Ruby Racca-MagaoTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Kimberly Ramirez conducted the unannounced annual inspection with the focus of the infection control domain. LPAs met with Wellness Director, Ruby Racca-Magao, who assisted with the visit. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which 9 may be bedridden. The hospice waiver is approved for 20 residents.

LPAs toured the facility and observed the following:
* The building consists of 5 floors. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor.
* Covid-19 signage are posted throughout the facility. Hand washing signs are posted in the bathrooms.
* Extra PPE supplies of at least 30 days are observed.
* The facility has a digital Covid-19 screening form for all staff and visitors.
* LPAs inspected rooms #107, #117, #212, #215, #308, #314, #404, and #405. The rooms are clean and have the required furnishings.
* Food supplies of 2 day perishable and a week of non-perishable are observed.
* Medications are centrally stored in the Wellness Office. LPAs reviewed 4 residents' medications and medications are being administered as prescribed. These 4 residents' files also have updated emergency contact information forms.
* 3 Staff and 4 Residents were interviewed.
* Staff were observed wearing a face mask.
* Staff are cleaning and disinfecting on each shift and more often for high touched surfaces.
* Per the Wellness Director, they have backup staff when needed and are following the strictest covid-19 guidance.

There are no deficiencies issued today. The exit interview was held. A copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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