Mission Lodge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 9:45am to conducted a 1 year annual visit to the facility above. LPA met Administrator Juan Marcos Ibarra and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted an Infection Control Plan to the department. The facility has a sign in and out kiosk for Staff, Residents and visitors. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) on hire and annual there after. Physical Plant & Environment Safety: The facility is 10 bedroom with 10 private bathrooms and 2 common areas restrooms currently occupying 7 residents and employs 32 staff and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors with sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a pendant system and pull cords in each residents bathroom. All pathways are clear of any obstruction. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills are conducted. Continued 809-C Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Staffing: The facility employes 32 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 03/29/2027. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. 5 files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's are in a binder for review. Internet is provided to each resident with confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Kitchen Cook has a valid Food Handler Certificate. Continued 809-C Incidental Medical & Dental: The facility has a medication room that is kept locked as well as one medication cart which are kept locked. Facility provides transportation to medical and dental appointments when needed. The facility uses a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR) for residents in care. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done at the Pharmacy or Administrator and staff do it at the facility. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 09/11/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were in accessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility does not currently have hospice residents in care. Hospice care plans are kept on file and up to date when a resident is on hospice services. The facility does not currently have residents on Home Health services. Home Health services records are kept on file if a resident is on services. The facility is a secured perimeter with a locked key coded gate for entry and exit. The facility has key coded locked gates on the enclosed patio in the back of the facility. LPA conducted interviews with 3 Staff. Exit interview conducted, no deficiencies cited, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jan 22, 2026

Type of visit: Required - 1 Year

At 10:00AM on 12/12/2024, Licensing Program Analyst (LPA) Jeffries conducted an unannounced annual inspection. LPA met with Administrator, Garrett Hanner, announced who he is and the reason for the visit. This facility is located on approximately 3 acres in a rural area. There is a gated complex with two identical facilities. This facility has 10 bedrooms and 12 bathrooms. Rooms are single and/or double occupancy which each of the 10 bedroom having a full privet bathroom, the other two bathrooms are resident, staff and visitor bathrooms that are in common areas. The carbon monoxides and smoke detectors are placed throughout the facility and are functioning properly. LPA observed 4 fire extinguishers placed throughout the facility all tested and in the green charge range. All passageways and exits are free and clear of debris. Administrator and LPA toured facility, all outdoor and indoor passageways are free of obstruction. There are no bodies of water on the premises. The facility is maintained in conformance with state fire marshal regulations. Smoke alarms and carbon monoxide detector in working order. Fire control system monitored 24 hours by independent protection company with monthly scheduled maintenance checks. Fire extinguishers have current tags and are all within the green charge indicator limits. The facility has a sprinkler system and was pressure tested by Great Western Alarm on 10/11/2024. Last fire drill conducted 11/19/2024. Facility maintains comfortable temperature of 72* Fahrenheit. Facility has call and egress system in place and in working order. Hot water temperature tested and read in random residents’ bathrooms within regulation standards (105*(f) -120*(f)). All bathrooms have non-skid mats and grab bars that are firmly secure on the shower and commode walls. Bedrooms have adequate lighting and appropriately furnished. All food is selected, stored, prepared and served in a safe and healthful manner. There is an adequate amount of perishable for 2 days and non-perishable food for 7 or more days. Freezer and refrigerator are clean and maintain proper temperature. There is an adequate number of staff to ensure provision of care and supervision to meet resident’s needs. LPA interacted with residents and view resident care with dignity and regard by staff. LPA reviewed random sample of residents’ files and random sample of staff files.CONTINUED on LIC9099-C Staff records reviewed, and staff has adequate training and current 1st Aid and CPR certificates. All staff has criminal record clearances. Staff files sampled showed sufficient hours of annual training to meet regulations required for annual training hours including dementia care training. Administrator has current administrator license. Residents’ files reviewed. All residents have signed medical assessments and are current within the last year. Medications are locked and stored in a secured room in locked storage. Prescription/nonprescription and PRN medications have signed and dated written orders from a physician. All medications are locked in a mobile medication cart. Medications are given as per doctor's order. LPA reviewed Emergency Disaster Plan and Infection Control plan. Administrator and LPA conducted a full review of annual care tool modules and noted no violations or citations. LPA conducted 4 staff and 3 resident interviews. Exit interview, report read, no deficiency cited, and report provided.the state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Prelicensing

At 10:00am Licensing Program Analyst (LPA) Jeffries arrived announced to the facility to conduct a pre-licensing facility inspection. LPA met with facility administrator Garrett Haner-Tomasko announced who he is and the reason for the visit. This facility is located on approximately 3 acres in a rural area. There is a gated complex with two identical facilities. This facility has 10 bedrooms and 12 bathrooms. Rooms are single and/or double occupancy which each of the 10 bedroom having a full privet bathroom, the other two bathrooms are resident, staff and visitor bathrooms that are in common areas. The facility has a sprinkler system and was pressure tested by Great Western Alarm on 12/14/2023. The carbon monoxides and smoke detectors are placed throughout the facility and are functioning properly. LPA observed 4 fire extinguisher placed throughout the facility all tested and in the green charge range. All passage ways and exits are free and clear of debris. Current fire clearance shows the facility is cleared for 15 non ambulatory residents under the current license. The new fire clearance for the new change of ownership (CHOW) pre license states that the facility is cleared for 9 non ambulatory residents. LPA and Licensee disused the need to address the new fire clearance with local fire authority based on the number if non ambulatory beds, considering the current specific population of resident currently residing at this facility. LPA advised Administrator to contact local fire authority and is addressed in this report as a technical advisement (TA). Administrator will contact LPA as to the resolution of how to address the non ambulatory resident numbers, considering the new fire clearance. . Administrator and LPA conducted a walking tour of the facility. LPA observed at least two days of perishable foods and at least 7 days of non perishable foods on hand for at least fifteen residents and staff. LPA noted that the facility was a comfortable 70 degrees (f). LPA tested the waster temperature to be within regulation range of 105*-120* (f). LPA noted that all bedrooms are properly furnished and have the appropriate lighting and linin. LPA noted that this facility has a locked med-cart located in the hallway office of the facility. CONTINUED on LIC9099-C LPA noted that the residents were engaged in daily activities and there is an activity calendar posted on the wall. LPA noted that all regulated posting were posted on the hallways in a conspicuous and accessible area. Administrator and LPA conducted a full review of the pre licensing care tools modules. LPA noted that only one TA was issued for fire clearance as noted in this report. LPA will follow up with and LIC-812 as to the resolution to this non ambulatory fire clearance numbers. LPA noted that no other technical, violation, or citation were noted on the full review of the pre licensing care tools review and no violations or citations were issued a result of the facility walk through inspection. Administrators and new licensee are currently running at least ten other residential care facilities for the elderly (RCFE) regulated from this local office and an LIC812 has been created to forego the COMP III class, as it has previously been administered Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Dec 22, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 15 Census (if any clients in care): 11 COMP II Participants: Zoltan Soo Interview Method: Telephone interview On November 15, 2023 at 11:00 AM, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant/Administrator. Copy of report sent by email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Nov 15, 2023