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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:58:56 PM

Substantiated


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
10/17/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251017161449
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: 51DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Clinical Director Maria RoledaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not assist resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/23/2025 regarding the above allegation. During today’s visit, LPA Ramirez was greeted by Clinical Director Maria Roleda and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 5 interviews (S1 – S5), Resident#1 – 6 (R1 – R6), Pendant call logs from October 01, 2025, through 10 14, 2025, Staff Timesheets for October 1, 2025, & October 14, 2025, and physical plant tour.


See 9099-C for continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 3
Control Number 28-AS-20251017161449
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: 10/23/2025
NARRATIVE
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The investigation revealed the following: regarding the allegation “Staff did not assist resident in a timely manner.” It is alleged staff are not assisting residents in a timely manner when residents push their pendant for assistance. Six (6) out of the six (6) residents interviewed corroborated this allegation. Resident interviews revealed that staff take between 10 mins to 45 mins to answer pendant calls. Record review of Pendant call logs from October 01, 2025, revealed the following: at 11:44am, R3 pressed their pendant for assistance and staff arrived 1hr 8mins 2 seconds later, at 6:50am, R1 pressed their pendant for assistance, staff arrived 41 mins 2 seconds later, and at 7:42am R2 pressed their pendant for assistance, and staff arrived 29mins 23seconds later to assist. Review of Pendant call log for October 14, 2025, revealed the following: at 7:22am, R6 pressed their pendant for assistance and staff arrived 1hr 58mins 18 seconds later, and at 7:51am, R3 pressed their pendant for assistance and staff arrived 1hr 38mins 40 seconds later to assist. Staff interviews corroborated the allegation. Staff interviews revealed that due to staffing absences, some residents are waiting longer than 5 mins for assistance. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) deficiency was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20251017161449
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
CCR
87468.2
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,
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Administrator will draft plan to address how the facility plans to deliver staff that are sufficient in numbers to provide care and supervision to residents in care. Plan must be received by 10/24/25.
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qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Residents calls for assistance were not met in a timely due to staffing shortages.
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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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
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