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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 08/16/2025
Date Signed: 08/16/2025 11:02:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/06/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250806154735
FACILITY NAME:CALIFORNIA MISSION INNFACILITY NUMBER:
198603161
ADMINISTRATOR:JARED GREENFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 41DATE:
08/16/2025
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Hayden Petrovick, Marketing DirectorTIME COMPLETED:
11:11 AM
ALLEGATION(S):
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Staff verbally abused a resident in care.
Staff are spraying chemicals in a resident's room.
Staff are serving food that is not of quality to a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to the facility to deliver findings. LPA met with Hayden Petrovick, Marketing Director and discussed the purpose of the visit.

During the visit, LPA took tour of common areas and R1 room. LPA interviewed S#6 via phone prior to visit.

On 08/14/2025 Licensing Program Analyst (LPA) Alberto Lopez made an initial 10-day visit to investigate the above allegations. LPA met with Maria Roleda, Clinical Supervisor and discussed the purpose of the visit.

The investigation consisted of: LPA took tour of common areas and resident’s room, interviewed five (5) staff (S#1-S#5), Six (6) residents (R#1-R#6), reviewed and obtained staff and residents rosters, food menus, food order form and alternative menu choices for residents on special diets. R1 physicians report, and incident report.
(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2025
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 2
Control Number 28-AS-20250806154735
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MISSION INN
FACILITY NUMBER: 198603161
VISIT DATE: 08/16/2025
NARRATIVE
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(continued from 9099)

The investigation revealed regarding allegation that Staff verbally abused a resident in care. It is alleged that a staff member harassed and verbally abused a resident in care.

LPA interviewed six (6) staff, and all six (6) staff denied the allegation. All six (6) staff stated they have never witnessed any staff being verbally abusive or harassing any residents. S6 denied being verbally abusive to resident and stated S6 goes out of way to accommodate resident. LPA interviewed six (6) residents and five (5) of five (6) residents were not able to corroborate the allegation. R1 stated there are no witnesses regarding verbal abuse. There is insufficient evidence to support this allegation.

Allegation: Staff are spraying chemicals in a resident's room. It is alleged that staff are spraying chemicals in the resident’s room, and it can be smelled on resident's clothing. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed six (6) residents and five (5) of six (6) residents were not able to corroborate the allegation. LPA toured resident’s room and room was not malodorous or smell like chemicals. Some staff stated that resident had requested that no chemicals be used in resident’s room, only water to clean and disinfect. R1 stated that R1 did mention to staff to only use water to clean and disinfect. LPA toured common areas and there was no chemical odor anywhere in the facility or in resident's room. R1 stated that it is R1 decision to not have any caregiver come into R1 room and not the staff at facility. There is insufficient evidence to support this allegation.

Allegation: Staff are serving food that is not of quality to a resident in care. It is alleged that the food is not of good quality and may have poison. LPA interviewed six (6) residents and four (4) of six (6) residents were not able to corroborate the allegation. One (1) resident stated she loved the food and especially the deserts. One resident stated that the food has too much salt, sugar and oil. One staff member stated that residents are provided with a menu checklist to choose alternate food items that fit their taste and/or diets. LPA toured the dining room during lunch hour, and the food was observed to be in good presentation and nutritious. LPA observed other residents with alternate meal items that they pre-selected in the early morning hours. All the residents observed in the dining room had finished their food during the visit. There is no evidence to support the allegation.

Based upon records review, interviews conducted, and observations, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Hayden Petrovick, Marketing Director. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2