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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 05/07/2024
Date Signed: 05/07/2024 03:06:42 PM

Document Has Been Signed on 05/07/2024 03:06 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:
05/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Winnie Tran - Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiencies noted on 4/16/24 and 4/18/24 during an annual visit. LPA met with Winnie Tran and explained the reason for the visit.

On 4/25/24 LPA Flores conducted a POC visit to clear the deficiencies noted during the annual visit and the following deficiencies were not cleared, civil penalties were noted during the visit 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 conditions. 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 was not cleared. On 5/7/24 LPA observed R1-R3 at the facility, reviewed physician's letter for R2 which notes R2 is no longer under a prohibited health condition. However, R1 and R3 continue to have a prohibited condition and reside at the facility.
*Civil penalties were noted 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. On 4/25/24 Deficiency was not cleared. On 5/1/24 administrator submitted to the department physician's letters for R2 and R4, which describes residents ambulatory status as non-ambulatory and not bedridden. Facility is licensed to have 1 bedridden resident. Therefore, deficiency is cleared as of 5/1/24.

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 Resident #1(R1) which notes full bed rails however R1 is not on hospice. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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: 05/07/2024
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Physician' order for Resident #5 (R5) does not identify the type of rails that R5 may use. No other bed rails request were obtained. On 4/25/24 Deficiency was not cleared. On 4/26/24 bed rail request was submitted for resident #6(R6).On 5/7/24 LPA Flores observed full bed rails on R1's bed, resident is not on hospice. Licensee must either replace rails with half bed rails or request an exception for full bed rails to the department. Resident #3's (R3) bed rails were removed. Bed rail physician's request was submitted to the department on 5/1/24 for resident #2 (R2). No bed rail request were obtained for resident #4. Deficiency not cleared.
*Civil Penalties were noted for failure to correct.*

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. On 4/25/24 Deficiency was not cleared. On 5/7/24 LPA toured the facility and observed cleaning supplies and solutions were under locked. Deficiency cleared as of 5/7/24.

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. On 5/7/24 LPA Flores reviewed TB test for R6. No TB test for R5 was obtained. Deficiency not cleared.
Civil Penalties were noted for failure to correct.*

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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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