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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850393
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:28:26 PM

Document Has Been Signed on 12/12/2024 01:28 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/
DIRECTOR:		SOO, ZOLTANFACILITY TYPE:
740
ADDRESS:5253 MONTEREY ROADTELEPHONE:
(805) 226-7431
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 15CENSUS: 11DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Administrator, Garrett HannerTIME VISIT/
INSPECTION COMPLETED:
01:43 PM
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 At 10:00AM on 12/12/2024, Licensing Program Analyst (LPA) Jeffries conducted an unannounced annual inspection. LPA met with Administrator, Garrett Hanner, 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 carbon monoxides and smoke detectors are placed throughout the facility and are functioning properly. LPA observed 4 fire extinguishers placed throughout the facility all tested and in the green charge range. All passageways and exits are free and clear of debris. Administrator and LPA toured facility, all outdoor and indoor passageways are free of obstruction. There are no bodies of water on the premises. The facility is maintained in conformance with state fire marshal regulations. Smoke alarms and carbon monoxide detector in working order. Fire control system monitored 24 hours by independent protection company with monthly scheduled maintenance checks. Fire extinguishers have current tags and are all within the green charge indicator limits. The facility has a sprinkler system and was pressure tested by Great Western Alarm on 10/11/2024. Last fire drill conducted 11/19/2024. Facility maintains comfortable temperature of 72* Fahrenheit. Facility has call and egress system in place and in working order. Hot water temperature tested and read in random residents’ bathrooms within regulation standards (105*(f) -120*(f)). All bathrooms have non-skid mats and grab bars that are firmly secure on the shower and commode walls. Bedrooms have adequate lighting and appropriately furnished. All food is selected, stored, prepared and served in a safe and healthful manner. There is an adequate amount of perishable for 2 days and non-perishable food for 7 or more days. Freezer and refrigerator are clean and maintain proper temperature. There is an adequate number of staff to ensure provision of care and supervision to meet resident’s needs. LPA interacted with residents and view resident care with dignity and regard by staff. LPA reviewed random sample of residents’ files and random sample of staff files.CONTINUED on LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/12/2024
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Staff records reviewed, and staff has adequate training and current 1st Aid and CPR certificates. All staff has criminal record clearances. Staff files sampled showed sufficient hours of annual training to meet regulations required for annual training hours including dementia care training. Administrator has current administrator license. Residents’ files reviewed. All residents have signed medical assessments and are current within the last year. Medications are locked and stored in a secured room in locked storage. Prescription/nonprescription and PRN medications have signed and dated written orders from a physician. All medications are locked in a mobile medication cart. Medications are given as per doctor's order. LPA reviewed Emergency Disaster Plan and Infection Control plan.

Administrator and LPA conducted a full review of annual care tool modules and noted no violations or citations. LPA conducted 4 staff and 3 resident interviews.

Exit interview, report read, no deficiency cited, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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