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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850393
Report Date: 12/22/2023
Date Signed: 12/22/2023 02:02:47 PM


Document Has Been Signed on 12/22/2023 02:02 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MISSION LODGEFACILITY NUMBER:
405850393
ADMINISTRATOR:SOO, ZOLTANFACILITY TYPE:
740
ADDRESS:5253 MONTEREY ROADTELEPHONE:
(805) 226-7431
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 12DATE:
12/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Administrator - Garrett Haner-TomaskoTIME COMPLETED:
02:00 PM
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 At 10:00am Licensing Program Analyst (LPA) Jeffries arrived announced to the facility to conduct a pre-licensing facility inspection. LPA met with facility administrator Garrett Haner-Tomasko announced who he is and the reason for the visit.
This facility is located on approximately 3 acres in a rural area. There is a gated complex with two identical facilities. This facility has 10 bedrooms and 12 bathrooms. Rooms are single and/or double occupancy which each of the 10 bedroom having a full privet bathroom, the other two bathrooms are resident, staff and visitor bathrooms that are in common areas. The facility has a sprinkler system and was pressure tested by Great Western Alarm on 12/14/2023. The carbon monoxides and smoke detectors are placed throughout the facility and are functioning properly. LPA observed 4 fire extinguisher placed throughout the facility all tested and in the green charge range. All passage ways and exits are free and clear of debris. Current fire clearance shows the facility is cleared for 15 non ambulatory residents under the current license. The new fire clearance for the new change of ownership (CHOW) pre license states that the facility is cleared for 9 non ambulatory residents. LPA and Licensee disused the need to address the new fire clearance with local fire authority based on the number if non ambulatory beds, considering the current specific population of resident currently residing at this facility. LPA advised Administrator to contact local fire authority and is addressed in this report as a technical advisement (TA). Administrator will contact LPA as to the resolution of how to address the non ambulatory resident numbers, considering the new fire clearance. .
Administrator and LPA conducted a walking tour of the facility. LPA observed at least two days of perishable foods and at least 7 days of non perishable foods on hand for at least fifteen residents and staff. LPA noted that the facility was a comfortable 70 degrees (f). LPA tested the waster temperature to be within regulation range of 105*-120* (f). LPA noted that all bedrooms are properly furnished and have the appropriate lighting and linin. LPA noted that this facility has a locked med-cart located in the hallway office of the facility.
CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MISSION LODGE
FACILITY NUMBER: 405850393
VISIT DATE: 12/22/2023
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LPA noted that the residents were engaged in daily activities and there is an activity calendar posted on the wall. LPA noted that all regulated posting were posted on the hallways in a conspicuous and accessible area.

Administrator and LPA conducted a full review of the pre licensing care tools modules. LPA noted that only one TA was issued for fire clearance as noted in this report. LPA will follow up with and LIC-812 as to the resolution to this non ambulatory fire clearance numbers. LPA noted that no other technical, violation, or citation were noted on the full review of the pre licensing care tools review and no violations or citations were issued a result of the facility walk through inspection.

Administrators and new licensee are currently running at least ten other residential care facilities for the elderly (RCFE) regulated from this local office and an LIC812 has been created to forego the COMP III class, as it has previously been administered

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC809 (FAS) - (06/04)
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