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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 10/14/2025
Date Signed: 10/14/2025 03:23:29 PM

Document Has Been Signed on 10/14/2025 03:23 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/
DIRECTOR:		JARED GREENFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 85CENSUS: 42DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Jared Green, Administrator and Maria Roleda, Wellness Director. TIME VISIT/
INSPECTION COMPLETED:
03:29 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Jared Green and Maria Roleda, Wellness Director, assisted LPA with the visit.

On today's date, LPA inspected the following domains

1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practices the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents, of which 9 may be bedridden, is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place.

3. Physical Plant/Environmental Safety: The facility consists of a 5-floor building. 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 floors. LPA inspected random rooms and are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room.

(See LIC 809C for continuation)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2025
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(continued from 809)
Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature was tested between 109.4 and 115.8 F which is within the Title 22 regulation of 105.0 – 120.0 degrees F. LPA also inspected the carbon monoxide detectors in the facility, are working properly. The facility has a telephone service on the premises.

4. Staffing: The facility has sufficient staffing to provide care and supervision to residents.

5. Personnel Record-Training: All the staff are over 18 years old and they are fingerprint clear and associated with the facility. LPA inspected four (4) staff files, and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Jared Green and his administrator certificate expiration date in 4/14/26.

6. Resident Record-Incident Reports: LPA inspected four (4) residents files and they all have the required documents in file which included: admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

7. Resident's Right: LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted, and LPA reviewed the calendar for the facility.

9. Food Service: The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room.

10. Incidental Medical and Dental: LPA inspected four (4) residents medication, and the medication is centrally stored and locked in the Wellness Center room, and they are accurate and updated and also contain 30 days’ supply of medication. The facility will also provide transportation to residents' medical and dental appointments.

11. Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610E) posted but needs updated to show one evacuation site out of the area. The last fire drill was conducted on 09/16/2025 and the last disaster drill was conducted on 06/06/2025. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are three (3) residents on hospice and two residents in home health. Individual Service Plan and appraisals are on resident's files for home health and hospice.

No deficiencies were observed during the visit. Technical advisories provided.

Exit Interview Conducted and a copy of the report was provided to Wellness Director Maria Roleda

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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