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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:11:56 PM

Document Has Been Signed on 04/16/2024 04:11 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:ACE SENIOR CARE MANOR, INC.FACILITY NUMBER:
197607681
ADMINISTRATOR/
DIRECTOR:		PEARL HEFACILITY TYPE:
740
ADDRESS:940 N. LAKE AVE.TELEPHONE:
(626) 398-2098
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Winnie Tan - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA)s Mary Flores and Christian Gutierrez conducted an unannounced annual visit at the facility using the inspection CARE tool. LPAs met with Winnie Tan and explained the reason for the visit. Administrator arrived 30 minutes later.

The facility is licensed to serve 1 bedridden and 5 non-ambulatory residents age 60 and above, with a hospice waiver for 1. The facility located in a commercial/residential area and consist of three (3) cottage units, each unit consist of a living room, kitchen, a bathroom, and two (2) resident rooms, a front yard, two (2) garage, laundry is located in the garage, and a shed.

LPAs toured the facility with Winnie Tan, and Checksim Lim and observed the following:
Facility is good repair indoor and outdoor. Food supplies were observed in each unit and no grains, no pastas, no rice, no breads, no fruits were observed, few vegetables and meats were observed. No sufficient food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Kitchen in unit #2 (942) floor was observed dirty and cleaning supplies were observed accessible to the residents in a kitchen cabinet, under sink cabinet, and mirror storage.
Unit #1(940) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap buildup and no skid mat was observed. Water temperature was tested at 109.4 degrees F.
Unit #2(942) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap mildew buildup and no skid mat was observed. Water temperature was tested at 120.9 degrees F.
Unit #3(944) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap/mildew buildup and no skid mat was observed. Water temperature was tested at 138.2 degrees F. Medication was observed in the refrigerator accessible to the residents. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 04/16/2024 04:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/16/2024 at 02:54 PM
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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in water temperature in unit #2 tested at 120.9 degrees F., and in unit #3 water temperature tested at 138.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will adjust water temperature and certify in writing that will ensure water temperature is within 105-120 degrees F by POC due date 4/17/24. Administrator will maintain a daily log of water temperature for unit #2 and #3 and will submit log within 7 days.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in kitchen in unit #2 had cleaning solution in a cabinet without a lock, cabinet under sink located in the hallway had disinfectant spray without a lock, and mirror cabinet in unit #2 and #3 had cleaning powder in a plastic bottle and can accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will ensure all items are inaccessible to the residents and will provide training to staff on section 87309. Administrator will provide a copy of training to the department by POC due date 4/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/16/2024 04:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/16/2024 at 02:54 PM
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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 3 staff, staff #1 did not have a background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will certify in writing that will ensure staff are fingerprint and associate to the facility before working to the department by POC due date 4/17/24. S1 left and will not return to work until cleared and associate.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service 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 in after review of each kitchen and garage LPAs did not observed a variety of food supplies suffiicent for 6 residents for at least 2 days of perishables and 7 days on non-perishables which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will purchase food supplies and submit a copy of receipts and pictures to the department by POC due date 4/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/16/2024 04:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/16/2024 at 02:54 PM
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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in medication for resident #1 (R1) was observed in the refrigerator accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will purchase a lock box to place in the refrigerator for medication storage and will submit picture to the department and will provide training to staff regarding proper storage by POC due date 4/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/16/2024 04:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/16/2024 at 02:54 PM
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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in bathroom's showers in each unit were observed with soap, and/or mildew buildup, and kitchen floor in unit #2 was not clean which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Administrator will clean and remove buildup from each shower and kitchen #2 and will submit a picture to the department by POC due date 4/23/24.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 in 3 out of 3 showers did not have a skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Administrator will purchase and place skid mats in each bathroom and will submit a picture to the department by POC due date 4/23/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681
VISIT DATE: 04/16/2024
NARRATIVE
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LPAs reviewed medication for 5 residents. LPAs reviewed staff roster and staff #1(S1) was observed working on unit #1 and does not have a background clearance, per administrator 4/16/24 was S1's first day working at the facility.

During this visit LPAs concluded three CARE tool domains: Physical plant, Food Services, and Incidental Medical. LPA Flores will return at a different time to continue annual visit.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Hongwei He staff and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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