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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440129
Report Date: 02/14/2025
Date Signed: 02/14/2025 04:35:04 PM

Document Has Been Signed on 02/14/2025 04:35 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MASONIC HOME FOR ADULTSFACILITY NUMBER:
011440129
ADMINISTRATOR/
DIRECTOR:		SOLEDAD MARTINEZFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 471-3434
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 242CENSUS: 151DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Soledad Martinez, Executive Director TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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At around 10:00am, Licensing Program Analysts (LPAs) K. Nguyen and Lori Alexander arrived unannounced to conduct an annual required inspection and met with Executive Director, Soledad Martinez. This facility is a Continuing Care Retirement Community (CCRC). The facility provides independent, assisted living and memory care.

LPAs with Soledad inspected the following: total of 20 rooms in independent living, assisted living and memory care, kitchen, dining area, activity room and other common areas. All showers/bathrooms were observed with grab bars and non-skid floors. Multiple fire extinguishers were observed in different locations that appear full and were inspected on 01/09/2025. LPAs observed sufficient supply of perishable and non-perishable foods. Hot water temperature measured at 110.1 degrees Fahrenheit in different rooms checked. Memory Care unit has a delayed egress system that was observed functional. Maintenance log for facility generator indicates last weekly inspection was conducted on 2/11/2025 and last monthly test was done on 1/24/2025. Facility has a current disaster plan and supplemental emergency disaster plan dated 1/9/2024. First aid kit was observed complete. Last disaster drill was conducted on 1/16/2025 and 1/23/2025 (lasted 5 days). Liability insurance effective date from 4/1/2024 to 4/1/2025.

LPAs inspected the Wollenberg Building which has 30 Memory Care residents, and Pavillion Building which consist of all AL residents. LPAs reviewed 13 staff and 15 resident files.

LPA reviewed 13 staff files 13 out of 13 staffs have health clearance on files.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection.

Exit interview conducted and a copy of this report provided via email to Executive Director.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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