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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320508
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:56:09 AM

Document Has Been Signed on 10/17/2024 10:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ACE ELDERLY HOMEFACILITY NUMBER:
198320508
ADMINISTRATOR/
DIRECTOR:		AGATEP,EVANGELINEFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 985-1059
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:01 AM
MET WITH:ADMINISTRATOR EVANGELINE AGATEPTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 10/17/2024 around 8am Licensing Program Analysts (LPA) Jose Calderon conducted an announced face to face visit with Administrator Evangeline Agatep for purpose of a pre-licensing evaluation for Ace Elderly Home. The requested capacity is for 6 adult residents of which there is 2 are bedridden and in hospice care. 4 ambulatory Adult Residents.

Currently there are 4 adult residents living at the facility. Facility is a 4 bedroom, 2 bathrooms, one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 4 chairs. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPA Calderon did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 4 Bedrooms are for ambulatory/non-ambulatory clients. Bedroom’s #1 and #2, #3 and #4 has one bed each, one chair, one-night stand, one lamp. There are dressers within the closet for each resident. Bedrooms #1, #2 #3 and #4 all comply with the requirement of 8 cubic feet of space. Bathrooms: Have a working toilet, wash basins, and walk-in shower. Bathroom #1 & 2 walk-in showers have grab bars. LPA Calderon observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ACE ELDERLY HOME
FACILITY NUMBER: 198320508
VISIT DATE: 10/17/2024
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Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" was noted. 2 Fire Extinguisher 1 mounted on the wall in the kitchen and the second in the hallway.
Food Service: Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is adequate; 7 days of dry food was found in the kitchen pantry which consisted of dry pasta, canned foods. Facility did have 7 days of emergency water located in the garage. Smoke Detectors: 5 smoke detectors are hard wired operated & working. 2 Carbon monoxide detector 1 located and mounted in the hallway and kitchen is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 41 degrees Fahrenheit for appropriate food storage. Freezer is at 19 degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 114 F. and #2 113 F. degrees, kitchen sink temperature tested at 115 F degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet, available for staff use but inaccessible to clients.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA Calderon did not observe any pet or bodies of water at the facility. LPA Calderon observe delayed egress, no chain locks, or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA Calderon did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 09/12/2024 for 2 bedridden/4 ambulatory clients with no special instructions. LPA Calderon did not observe delayed egress, no chain locks, or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ACE ELDERLY HOME
FACILITY NUMBER: 198320508
VISIT DATE: 10/17/2024
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Component III: (10/17/2024) about how to operate the facility within substantial compliance was reviewed by the licensee at this time. The licensee did not have any questions regarding component III for the LPA.

An exit interview was conducted, and a copy of this report has been furnished to the applicant Administrator Evangeline Agatep by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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