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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607431
Report Date: 05/09/2023
Date Signed: 05/09/2023 09:30:44 PM

Document Has Been Signed on 05/09/2023 09:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A + SINCERE CARE MANORFACILITY NUMBER:
197607431
ADMINISTRATOR:FENGPEI QINFACILITY TYPE:
740
ADDRESS:5029 MCCLINTOCK AVE.TELEPHONE:
(626) 579-7795
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 5DATE:
05/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator HeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction visit stemming from Annual required visit dated 05/02/23. LPA was met by Administrator He and explained the purpose of the visit,

LPA toured shared and private resident bathrooms, and kitchen area. LPA observed these areas to be clean and no other deficiencies were observed. LPA observed pad locks on kitchen cabinets that contained sharps and cleaning solutions. LPA reviewed “Emergency Log” that list several emergency trainings for staff. LPA reviewed Medications Administration Record (MAR) for 5 residents, for the month of May 2023. LPA observed auditory devices in living room sliding door and resident room# 5; were on switched into “ON” mode.

No deficiencies or heath and safety violations were observed at this time. Exit interview was conducted and a copy of this report will be emailed due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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