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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:51:44 PM

Document Has Been Signed on 06/10/2022 04:51 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MASONIC HOMES FOR ADULTSFACILITY NUMBER:
191592287
ADMINISTRATOR:JUDY FIGUEROAFACILITY TYPE:
741
ADDRESS:1650 EAST OLD BADILLO STTELEPHONE:
(626) 251-2200
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 112CENSUS: 60DATE:
06/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Administrator Sandra FaheyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Maldonado conducted an unannounced visit to the above mentioned facility. LPA met with administrator Sandra Fahey and toured the facility.

During the visit, LPA obtained a copy of the resident and staff roster. While reviewing file for Staff #1 (S1), it was discovered that S1 has been employed at the facility since 04/18/2016 and was not associated to the facility until 06/09/2022.

California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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Document Has Been Signed on 06/10/2022 04:51 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 06/10/2022 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MASONIC HOMES FOR ADULTS
FACILITY NUMBER: 191592287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2022
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by:
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The facility will ensure all staff members are fingerprint cleared and associated prior to working or being present at the facility. The licensee will submit a plan of action on how they will ensure individuals will not be present at the facility until they are cleared by POC due date.
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During S1 file review, it was discovered that S1 was not associated to facility since employment on 04/18/2016. S1 was assciated until 06/09/2022 and this caused an Immediate Health and Safety risk to clients in care. Civil Penalty assessed $500.
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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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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