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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:24:46 PM

Document Has Been Signed on 04/25/2024 03:24 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:
04/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:Winnie Tan - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies noted during annual visit conducted on 4/16/24 and 4/18/24. LPA met with Winnie Tan and explained the reason for the visit. Hongwei He assistant administrator arrived 10 minutes later.

On 4/16/24 and 4/18/24 LPA noted the following Type A/B deficiencies during the annual visit:
Type A - 87307 Personal Accommodations and Services - 1 out of 6 residents bedroom, room #6 is being used by a resident and a staff. On 4/25/24 LPA Flores observed the bed was removed and a chair was provided. Deficiency cleared as of 4/25/24.

Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health condition. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency not cleared.*Civil Penalties will be noted today for failure to correct.*

Type A - 87204(a) Limitations-Capacity and Ambulatory Status - On 4/18/24 During file review LPA observed 3 out of 6 residents are bedridden per physician's report. ON 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1,R2,Resident #4(R4) ambulatory status. R1,R2, R4 were observed at the facility at the time of the visit. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.*

Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for R1 which notes full bed rails however R1 is not on hospice and physician' order for R5 does not identify the type of rails that R5 may use. No other bed rails request were obtained. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 3
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: 04/25/2024
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Type A - 87303(e) (2) Maintenance and Operation - On 4/16/24 LPA tested water temperature in unit #2 tested at 120.9 degrees F., and in unit #3 water temperature tested at 138.2 degrees F. On 4/25/24 LPA Flores tested the water temperature in the bathrooms' in unit #2 and #3 and tested between 107-113.7 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 4/25/24.

Type A - 87309(a) Storage Space - On 4/16/24 LPA observed 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. On 4/25/24 LPA observed detergent in can and half plastic bottle in mirror cabinet in outside sink in unit #2 and can with detergent in mirror cabinet in bathroom of unit #3. Deficiency not cleared.
*Civil Penalties will be noted today for failure to correct.*

Type A - 87355(d)(3) Criminal Record Clearance - On 4/16/24 LPA observed staff #1(S1) working at the facility and upon file review observed S1 did not have a background clearance. On 4/25/24 LPA reviewed Guardian list and Staff #1 is cleared and association as 4/17/24. Deficiency cleared as of 4/25/24.

Type A - 87555(b)(26) General Food Services Requirements - On 4/16/24 LPA review each kitchen and garage and did not observed a variety of food supplies sufficient for 6 residents for at least 2 days of perishables and 7 days on non-perishables. On 4/25/24 LPA observed food supplies in each refrigerator sufficient for 2 days of perishables, and 7 days of non-perishables for 6 residents only. Deficiency cleared as of 4/25/24.

Type A - 87465(h)(2) Incidental Medical and Dental Care Services - On 4/16/24 LPA observed medication for resident #6 (R6) was observed in the refrigerator accessible to the residents. On 4/25/24 LPA observed combination lock box for medication inside refrigerator. Deficiency cleared as of 4/25/24.

Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.*
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 04/25/2024
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Type B - 1569.695(d) – Health and Safety Code - On 4/18/24 Emergency Disaster Plan was last reviewed on 8/30/22, plan does not meet the standards of current version LIC 610E(3/19). On 4/25/24 LPA reviewed a copy of LIC 610E(3/19). Deficiency cleared as of 4/25/24.

Type B - 87705(c )(5) Care of Person with Dementia - On 4/18/24 LPA observed R6 last physician's report is dated 8/15/20. On 4/25/24 LPA reviewed physician's report for R6 dated 12/7/23. Deficiency cleared as of 4/25/24.

Type B - 87303(a) Maintenance and Operation - On 4/16/24 LPAs observed buildup of soap and mold in each shower(3) and kitchen #2. On 4/25/24 LPA observed each shower and kitchen #2 which were observed clear of buildup and clean. Deficiency cleared as of 4/25/24.

Type B - 87303 (e)(5) Maintenance and Operation - On 4/16/24 LPA observed that 3 out of 3 showers did not have a skid mat. On 4/25/24 LPA observed a skid mat in each shower. Deficiency cleared as of 4/25/24.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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