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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:57:36 AM

Document Has Been Signed on 05/10/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ACE SENIOR CARE MANOR, INC.FACILITY NUMBER:
197607681
ADMINISTRATOR:PEARL HEFACILITY TYPE:
740
ADDRESS:940 N. LAKE AVE.TELEPHONE:
(626) 398-2098
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 3DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda King, caregiverTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced site visit for the required annual inspection. Upon arrival at the facility, LPA met with Staff, Linda King, who assisted with the visit. Administrator, Pearl He, arrived shortly thereafter to join the inspection. The facility is licensed to serve a total of 6 residents, one may be bedridden and 5 non-ambulatory ages 60 and above. The hospice waiver is approved for 1 resident. LPA utilized the infection control domain for the inspection and also reviewed medications and food supplies.

The facility consists of 3 separate units on the same lot. Each unit consists of 2 resident bedrooms, one bathroom, living room, dining room, and kitchen. There are 2 separate garages located in the back. There are no pools or bodies of water at the location.
During today's visit, LPA observed one bedridden resident in the front unit (940), no residents residing in the middle unit (942), and 2 residents in the back unit (944). The facility has a sign in station with masks and hand sanitizers available at each of the unit. Covid-19 signage are posted at each of the units. LPA requested for the Administrator to include the hand washing signage in the bathrooms and kitchen. There were at least 30 days of PPE supplies in storage. Disinfectants and cleaning solution are properly stored making them inaccessible to residents. Staff were observed wearing face masks. LPA reviewed the medications for all 3 residents.
LPA issued citations for the following items:
* A week of non-perishable items were not observed at the facility.
* 2 of the medications for Resident #3 had not obtained the refills, therefore, LPA observed the bottles empty. Per the administrator, the family obtains the refill but has not brought them over.

The deficiencies are cited on the LIC809D. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 11:57 AM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/10/2022 at 10:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(3)
Incidental Medical and Dental Care Services
(a)(3) There shall be arrangements for separation and care of residents whose illness requires separation from others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for Resident #3 whose medications Ergocalciferol 1250 mcg and Carvedilol 6.25 mg were out of pills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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The Administrator shall ensure that resident #3 medications are refilled in advance when medications run low. Administrator shall submit proof that the medication is refilled and given by 5/11/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2022 11:57 AM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/10/2022 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
8755 General Food Services Requirements:
b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for not maintaining a minimum of one week of nonperishable foods at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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The Administrator shall purchase at least of nonperishable items to store at the facility. The POC shall be sent to LPA by 5/17/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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