197607681-4-30-2024-28-AS-MGFS-D4TST3-20240430140851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:09:04 PM

Document Has Been Signed on 04/30/2024 02:09 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 HE		FACILITY TYPE:	740
ADDRESS:	940 N. LAKE AVE.		TELEPHONE:	(626) 398-2098
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 6	DATE:	04/30/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:52 PM
MET WITH:	Checksim Lim - House Manager		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

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	Licensing Program Analyst (LPA) Mary Flores conducted a visit to provide corrected plan of correction (POC) visit version for report provided on visit conducted on 4/25/24. LPA met with Checksim Lim and explained the reason for the visit. On 4/25/24 LPA Flores conducted a plan of correction visit and noted under Type B - 87458(b)(1) Medical Assessment - civil penalties were noted in error. Therefore, LPA is creating today's report to correct that. 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.* (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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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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: 04/30/2024

NARRATIVE

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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.*
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.
(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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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: 04/30/2024

NARRATIVE

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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.

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.

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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