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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607431
Report Date: 11/05/2022
Date Signed: 11/16/2022 09:23:16 AM

Document Has Been Signed on 11/16/2022 09:23 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A + SINCERE CARE MANORFACILITY NUMBER:
197607431
ADMINISTRATOR:FENGPEI QINFACILITY TYPE:
740
ADDRESS:5029 MCCLINTOCK AVE.TELEPHONE:
(626) 579-7795
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 5DATE:
11/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Caregiver, Luz Yanina CotaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted a Required Annual visit. LPA met with caregiver, Luz Yanina Cota who assisted with the tour of the facility. At 2:30pm, Administrator Hong Wei He arrived. The facility cares for elderly residents with dementia and licensed to serve 1 bedridden and 5 non-ambulatory residents. Waiver is approved to retain 1 resident on hospice. There is currently no resident on hospice. This single-story home contains six (6) bedrooms, of which one (1) is for the caregiver, three (3) bathrooms, a living room, kitchen, dining area, backyard, and storage room in the backyard.LPA observed that the facility does not have a swimming pool or other bodies of water.

The facility was toured along with caregiver Luz Yanina Cota and observed/inspected the following:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet. Caregiver screened the LPA upon entry.
  • COVID-19 posters and signs were placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the supply closet inside the home and in the storage room in the backyard.
  • Staff wore a face mask throughout her shift.
  • (6) Bedrooms have the required furniture such as bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition.
  • 3 bathrooms have the required grab bars in the shower and near the toilet. The bathrooms are clean and have the required hygiene items.However bathroom # 2's shower is not being used. There are boxes and supplies placed in the shower area. Bathroom #3 hot water reading in the shower is 121.3 deg. F, which is not within the required Titled 22 regulations.

***Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2022
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 4
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: A + SINCERE CARE MANOR
FACILITY NUMBER: 197607431
VISIT DATE: 11/05/2022
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  • At 2:05pm, the hot water temperature in the kitchen was 116 degrees during the visit. At 2:10pm, bathroom #1 hot water temperature was 118.9 deg F and bathroom #2 reading was 119.3 deg. F. All are within the required 105 - 120 degrees.
  • The facility temperature at the time the visit was comfortable.There is sufficient lighting throughout the facility.
  • There are smoke detectors in the bedrooms and common areas and carbon monoxide detector near the kitchen and are working properly.
  • The kitchen was inspected. There is sufficient 2-day perishable and 7-day non-perishable food. During the visit, LPA observed the cleaning solutions are unlocked under the kitchen sink cabinet which is accessible to residents.
  • There are cameras in the common areas and no audio. LPA did not observe any cameras in the private areas.
  • LPA observed one (1) fire extinguisher in the kitchen and is fully charged and last serviced on February 10, 2021.
  • LPA observed that the auditory device on one of the exit doors next to Bedroom #3 is inoperable.
  • The laundry area is located outside and LPA observed the cleaning/laundry supplies are out and accessible to residents.
  • Medications were locked and centrally stored. Medications were reviewed for all residents and facility maintained a 30-day supply of medications. Residents' medications were not documented properly.
  • The common areas such as living room and dining room are clean and have the required furniture.
  • The front yard is well maintained. There is a empty water fountain in the backyard.
  • The backyard has a shaded area and sitting area. The backyard has been designated as the visitor area during the COVID-19 pandemic.
  • Clients files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations Client files were inspected, and emergency contact information was up to date.
  • Hongwei He's Administrator certificate expires on 8/06/2023.
  • Staff files were reviewed to confirm health screenings and fingerprint clearances.
  • Residents have complete appraisals on file. Residents have complete admission agreements on file.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are documented on 809D. Exit interview held. A copy of the report and appeal rights were provided to the Administrator, Hongwei He.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/16/2022 09:23 AM - It Cannot Be Edited


Created By: Bennette Pena On 11/05/2022 at 03:58 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: A + SINCERE CARE MANOR
FACILITY NUMBER: 197607431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which the hot water temperature in bathroom #3 read at 121.3 degrees F which is not within the Title 22 Regulations, which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/07/2022
Plan of Correction
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The Administrator will send the receipts and work order from the plumber/handyman who will fix the hot water temperature in the sink and shower in bathroom #3 to LPA by email or fax on or before the POC due date.
Type A
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which the auditory device in one of the exit doors next to Bedroom #3 is inoperable, which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/07/2022
Plan of Correction
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The Administrator will send a copy of the receipts of the new auditory device or the battery replacement to LPA by email or fax on or before the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/16/2022 09:23 AM - It Cannot Be Edited


Created By: Bennette Pena On 11/05/2022 at 03:58 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: A + SINCERE CARE MANOR
FACILITY NUMBER: 197607431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which LPA observed cleaning solutions and disinfectants were stored under the kitchen sink cabinet unlocked and accessible to residents. Additionally, there were laundry soaps, cleaning solutions out and open next to the washing machine in the laundry area. which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/07/2022
Plan of Correction
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The Administrator will send pictures of the kitchen cabinet with lock and show the cleaning solutions stored inside. Administrator will also send pictures of the laundry area without the hazardous materials and laundry soaps to LPA by email or fax on or before the POC due date.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in which LPA observed that the Medication Administration Records (MARs) for all 5 residents are not updated and medications are not recorded properly which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/07/2022
Plan of Correction
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Administrator will schedule an in-service training on Medication Management for all facility staff in charge of medication management. A copy of the materials discussed during the training along with signatures of staff present must be forwarded to CCL by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
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