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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 03/21/2026
Date Signed: 03/21/2026 10:51:30 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
02/26/2026 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260226083245
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: 59DATE:
03/21/2026
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Food service Director Juan SantiagoTIME COMPLETED:
10:59 AM
ALLEGATION(S):
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Staff does not ensure residents are provided a safe environment resulting in harrassment.
Staff does not ensure resident's room is clean and sanitized.
Staff do not ensure the facility is properly maintained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to deliver findings for the above allegations. LPA met with Food service Director Juan Santiago, and discussed the purpose of the visit.

On 03/03/2026 The investigation consisted of LPA reviewing and obtaining staff and resident rosters, interviewed five (5) staff S#1 -S#5 and seven (7) residents R#1 – R#7. Reviewed and obtained R1 physicians report, R1 care plan and taking a tour of common areas, R1 room and random rooms. Reviewed and obtained chain of emails between R1 and facility

03/21/2026 The investigation revealed regarding allegation: Staff does not ensure residents are provided with a safe environment resulting in harassment. It is alleged that residents in adjacent rooms are talking loudly and disturbing the peace of resident in early morninig hours and staff are not addressing the issue.
(continued on 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2026
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 2
Control Number 28-AS-20260226083245
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: 03/21/2026
NARRATIVE
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(continued from 9099)
LPA interviewed five staff (5) and all five (5) staff denied the allegation. LPA interviewed seven (7) residents in adjacent rooms to R1 and four (4) of seven (7) residents could not corroborate the allegation. Two (2) residents stated that they had a loud verbal disagreement recently, that is was only one day. They stated it had nothing to do with R1, and that it has not occurred again. Both residents stated their issue has been resolved between them. LPA explained this to R1 and R1 stated she understands. There is not enough evidence to substantiate this allegation.

Staff does not ensure resident's room is clean and sanitized. It is alleged that R1 room is not being clean and sanitized. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated that resident has canceled room cleaning when scheduled and have refused to allow entry to housekeeping staff at times. LPA interviewed seven (7) residents and six (6) of seven residents could not corroborate the allegation. R1 admitted that R1 has cancelled scheduled room cleanings several times and stated that R1 does not want staff in R1 room when R1 is not present because things have gone missing before. LPA tour R1 room and it appeared clean. R1 stated outside service cleans room. There is insufficient evidence to support this allegation.

Staff do not ensure the facility is properly maintained. It is alleged that R1 stove is uncleaned, toilet is leaking and cover for drawer is loose and needs repair and facility has not addressed the issues. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. One staff member stated that as soon as they get a work order, they are on it right away. Records reviewed show that R1 requested to have her toilet repaired on 2/25/2026 and staff asked which dates would work for R1. Records show toilet was repaired on 02/27/2026 and R1 confirmed this. R1 alleged that there was a natural gas leak in room and called the Gas company. Gas company arrived and discovered that R1 does not have any appliance that uses natural gas and they did not detect any gas leak. One staff member stated that staff used a little spray of W40 to loosen bolt on toilet to repair it and that is what resident smelled. R1 agreed that was the smell after being told. On 03/04/2026, R1 alerted staff that there was a cover that came off a drawer and the facility had that repaired on 03/04/2026. There is insufficient evidence to substantiate this allegation.

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: 03/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2