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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 01/24/2026
Date Signed: 01/24/2026 12:02:50 PM

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
12/10/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251210091356
FACILITY NAME:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:JARED GREENFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 57DATE:
01/24/2026
UNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Hayden Petrovick, Marketing Director TIME COMPLETED:
12:06 PM
ALLEGATION(S):
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Staff did not provide meals to resident
Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to investigate the above allegations. LPA met with Hayden Petrovick, Marketing Director and the purpose of the visit was discussed.

12/16/2026 - The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation.
Due to time constraints, needs further investigation. LPA will return another day to complete investigation.

12/15/2026 - Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Wellness Coordinator Maria Cruz and the purpose of the visit was discussed. (Continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2026
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 3
Control Number 28-AS-20251210091356
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 - ROSE MANOR
FACILITY NUMBER: 198603163
VISIT DATE: 01/24/2026
NARRATIVE
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(continued from 9099)
The investigation consisted of LPA taking a tour of facility, interviewing two (2) staff (S#1-#2), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, and R1 care plan.

The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation.

The investigation revealed: Regarding Allegation: Staff did not provide meals to resident. It is alleged that staff did not provide meals for resident one day.

LPA interviewed five (5) staff and all five staff were aware that resident missed all three meals on 12/01/2025. Several staff stated that resident usually went to the dining hall on the fifth floor to eat meals. Culinary supervisor noticed she had not seen resident that day and asked another staff member if she knew about the resident.. The staff member answered with “resident is OK” and never checked on resident. Resident was receiving escorts to meals when she first arrived at the facility on care plan that was created on 06/19/2024. Effective 04/15/2025 an updated care plan was created and removed wellness checks and meal escorts to the dining room.

The resident should have no expectation for staff to check on resident or to deliver a meal tray to resident’s room on this day according to the services agreed upon by the resident and facility on 04/15/2025. There is insufficient evidence to support this allegation. (continued)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20251210091356
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 - ROSE MANOR
FACILITY NUMBER: 198603163
VISIT DATE: 01/24/2026
NARRATIVE
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(continued)

Allegation: Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours. It is alleged that staff neglected resident after a fall that resulted in resident being on the floor for twelve hours. Resident had wellness checks removed from care plan effective 04/15/2025. The resident was provided with a call pendant to press in case resident required assistance; however, resident did not press the pendant at any time during the time resident spent on the floor. According to the care plan effective 04/15/2025, the resident should have no expectation of a wellness check on 12/01/2026.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3