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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:33:50 PM

Document Has Been Signed on 04/18/2024 02:33 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:
04/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Linda King - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted a continue unannounced annual visit at the facility using the inspection CARE tool. LPA met with Linda King and explained the reason for the visit. Assistant Administrator arrived 30 minutes later.

During this visit LPA completed the following domains: Infection Control, Operational Requirements, Staffing
Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Resident Records / Incident Reports, Disaster Preparedness, Residents with Special Health Needs.

LPA Flores reviewed files for 5 residents, per file review Resident #1-#3(R1-R3) have a prohibited health condition and are not receiving hospice services. Resident #3(R3), R1,and R2 are bedridden per physician's report, facility has a fire clearance for 1 bedridden resident and is currently operating outside their license. R1 and R3 have full bed rails in their beds and are not receiving hospice services. Resident #4-#6(R4-R6) and R2 have half bed rails in their beds and no bed rail physician order/request was observed in their files. R5 and R6 do not have a TB test clearance in their file. R6's last physician report is dated 8/15/20 and has a dementia diagnosis.
LPA reviewed 5 staff, facility's Infection Control plan and Emergency Disaster Plan (LIC 610E 10/03) last reviewed on 8/30/22. Last fire drill was conducted on 3/29/24. LPA obtained a copy of Infection Control PLan and Liability Insurance.
During initial visit on 4/16/24, LPAs Flores and Gutierrez observed two beds and male's clothes and shoes in room #6 upon asking the reason staff #2(S2) and administrator stated, S2 sleeps in resident's room #6 per family's request.

Deficiencies are 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: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 04/18/2024 02:33 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/18/2024 at 11:19 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in 1 out of 6 residents bedroom, room #6 is being used by a resident and a staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator will ensure each resident room is used as licensed by individual use,will certify in writing that understands 87307, will submit to the departmnet, and will provide a chair for staff in room #6 to use while providing care by POC due date 4/19/24.
Type A
Section Cited
CCR
87615(a)(2)
87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 6 residents, R1 - R3 have a prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator will certify in writing that understands facilty may not retain or accept residents with prohibited health conditions per Title 22, submit to the department, and will assist with relocation of R1-R3 to higher level of care by POC due date 4/19/24.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/18/2024 02:33 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/18/2024 at 01:16 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

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 in 3 out of 6 residents are bedridden per physician's report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator will certify in writing that understands facilty may not go beyond the capacity of license while providing care, submit to the department, and will assist with reasses or relocate R1, R2, and R4 to higher level of care by POC due date 4/19/24.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 in 6 out of 6 residents have bed rails in their beds and do not have a physcian's order/request on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator will obtain a physician's order/request for each resident using a bed rail R1-R6 , will maintain in file for review, and will submit to the department by POC due date 4/19/24.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/18/2024 02:33 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/18/2024 at 01:16 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents, R5-R6 do not have a TB clearance in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator will obtain TB clearance for R5-R6 and submit a copy to the department by 4/25/24.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Emergency Disaster Plan was last reviewed on 8/30/22, plan does not meet the standards of current version LIC 610E(3/19) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator will update Emergency Disaster Plan to meet the current guidelines and will submit a copy to the department by POC due date 4/25/24.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/18/2024 02:33 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/18/2024 at 01:16 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents, R6 last physician's report is dated 8/15/20 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator will obtain a current physician's report for R6 and will submit a copy to the department by POC due date 4/25/24.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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