<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607681
Report Date: 06/30/2022
Date Signed: 06/30/2022 12:56:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/27/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220127150822
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:
06/30/2022
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Pearl He, AdministratorTIME COMPLETED:
01:04 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not allowing visitors.
Facility not taking prevention measures to prevent the spread of COVID-19.
Facility not allowing visitors.
Facility storing expired food.
Facility refrigerator is unsanitary.
Facility did not properly label food items.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Lopez made subsequent visit to facility to investigate the above allegations. Initial visit was on 01/31/2022. LPA was greeted by care giver Linda Pamintuan and Administrator Pearl He arrived a short time later. LPA explained the purpose of the visit. LPA took tour of facility with administrator.
The investigation consisted of interviews with administrator and 2 staff who were on duty. 2 residents at facility could not be interviewed and 1 resident was not at facility at time of visit.

Allegation: Facility not allowing visitors.
Administrator and 2/2 staff stated that visitors are allowed, and LPA observed visitor policy and sign in log of visitors for the current month.
Allegation: Facility not taking prevention measures to prevent the spread of COVID-19.
Administrator and 2/2 staff stated that they always wear mask and sanitize surfaces to prevent spread of covid-19. LPA was screened at facility and temperature taken. LPA observed PPE supllies and staff wearing mask.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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 4
Control Number 28-AS-20220127150822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 06/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility did not properly label food items.

Administrator and 2/2 staff stated they always label food properly before storing food. LPA observed and inspected 2 refrigerators/freezers at facility and both had food that was properly stored.

(For the remaining allegations please see 9099A)



Based on the interviews conducted with the staff and observation, there was not enough supportive evidence to concur with the reported allegations.

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 above are s UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal rights was provided to Administrator Pearl He
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/27/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220127150822

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:
06/30/2022
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Pearl He, AdministratorTIME COMPLETED:
01:04 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility refrigerator is unsanitary.
Facility storing expired food.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The investigation was based on observation of refrigerators and food items at the facility at time of visit.

Allegation: Facility refrigerator is unsanitary.

LPA inspected 2 refrigerators/freezers at facility and both are in unsanitary condition.

Allegation: Facility is storing expired food

LPA observed one small package of convient snacks with expiration date of MAY 2022.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220127150822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2022
Section Cited
CCR
87555(a)
1
2
3
4
5
6
7
General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents..... All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement was not met evidenced by:
1
2
3
4
5
6
7
Licensee stated it was caregiver item and disposed of expired food item during visit. Licensee shall conduct a regular inventory of all food goods and discard all expired foods.

Submit a written plan stating what was done, and proof of staff training by POC due date.
8
9
10
11
12
13
14
Based on observation, on 6/30/22 the facility had one expired food item in refrigerator. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
07/07/2022
Section Cited
CCR
87555(b)(29)
1
2
3
4
5
6
7
b (b) The following food service requirements shall apply: All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement was not met evidenced by:
1
2
3
4
5
6
7
Licensee cleaned both refrigerators during visit.

***no further action is required***
8
9
10
11
12
13
14
LPA observed both refirgrators and the freezer are in unsanitary condition.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4