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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607431
Report Date: 05/02/2023
Date Signed: 05/02/2023 11:11:11 PM

Document Has Been Signed on 05/02/2023 11:11 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: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:
05/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Administrator HeTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 05/01/2023 at 12:30 pm. LPA was met by Staff S2 and explained the purpose of the visit. Administrator Hongwei He later arrived to assist in tour. Facility is licensed to serve elderly residents over the age of 59 and is licensed to serve residents with dementia. The facility may retain 1 bedridden resident and 5 non-ambulatory residents. Waiver is approved for 1 hospice resident although, the facility currently does not have a hospice resident in care. LPA requested and obtained a copy of Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 12:53 pm and was led by Administrator He. The Facility is a single-story dwelling located on a residential street. The facility consists of five (1) client bedrooms, two (2) shared bathrooms, one (1) staff bedroom, living room, kitchen, dining room, front yard, and backyard.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen appliances to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 107.6 degrees F. LPA observed kitchen cabinet located near stove, containing knives and sharps, to be accessible to residents in care. LPA observed a padlock on cabinet, but no locking mechanism was placed to secure cabinet. When LPA questioned staff, staff stated they could not find lock at this time. LPA observed kitchen sink cabinet containing insect/bug spray and cleaning solutions to be accessible to residents in care. LPA observed a padlock on cabinet, but no locking mechanism was placed to secure cabinet. Kitchen walls and ceiling were observed to contain light reddish/orange splatter, stove backsplash contained caked grease and dirt, surrounding stove cabinets above and below contained cake grease and dust bunnies, stove venting was observed to be dirty and contained caked grease, kitchen floors were observed to be dirty and sticky.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and 4 chairs. Living room was observed to contain plenty of seating, and plenty of lighting. LPA observed front door screen to be torn by handle.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2023
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 6
Document Has Been Signed on 05/02/2023 11:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/02/2023 at 04:04 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Medications Administration Record (MAR) was not completed for 5 out of the 5 residents in care for the month of May 2023, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee will retrain staff on proper documentation of medications dosage and storage. Licensee will maintain medication dosage logs. Proof of staff re-traning and staff receiving re-training is required to be emailed to LPA by POC due date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, knives and sharps located near kitchen cabinet stove were accessible, padlock was observed on cabinet but locking mechanism was missing, the licensee did not comply with the section cited above in 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee will ensure staff places locking mechanism back on padlock immediately after not in use, as to ensure inaccessible to residents. Staff moved knives and sharps to secure location till locking mechanism can be placed back on padlock. Licensee will re-train staff on safe keeping and securing knives and other items that could constitute a danger to resident(s). Proof of staff re-traning and staff receiving re-training is required to be emailed to LPA by 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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/02/2023 11:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/02/2023 at 04:04 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, kitchen sink cabinet conating 2 cans of insect/bug spray, various bottles of cleaning solutions, to be accessible and LPA observed a padlock but no locking mechanism was observed, the licensee did not comply with the section cited above in 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee will re-train staff on safe guarding of over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. Licensee will provide LPA with proof of staff receiving training via email by POC due date. Staff later found locking mechanism and placed on padlock cabinet.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, auditory devices in resident rooms sliding doors and exits were not placed in "ON" mode, LPA had to switch "ON", the licensee did not comply with the section cited above in 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee will ensure auditory devices remain in "ON" mode. Licensee will provide a training to staff and send proof of staff receveing training to LPA no later than POC 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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/02/2023 11:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/02/2023 at 04:04 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, kitchen walls, kitchen ceiling, stove back splash, kitchen stove vent, and kitchen cabinets above and below surrounding stove; all contained caked on grease, dirt, grime and front door screen is torn, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Licensee will clean all areas mentioned. Licensee will replace front door screen. LPA will return to facility to ensure corrections have been made by POC date. Licensee will ensure staff cleans and maintains above mentioned areas on a regular basis.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, shared resident bathroom#1 and private resident bathroom#1 floors and showers contained caked dirt and grime,kitchen floors were observed to be dirty, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Licensee will ensre staff cleans above mentioned areas and maintains above mentioned areas. LPA will return to facility to ensure corrections have been made by POC date. Licensee will ensure staff cleans and maintains above mentioned areas on a regular basis.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/02/2023 11:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/02/2023 at 04:04 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 1 walker, and 2 folding commodes were observed being stored in private resident bathroom#1 shower, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Licensee will store excessive items in another location as to ensure residents have access to shower. Licensee will not use bathroom shower as stotage.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA could not locate proof of drills, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Licensee will maintain emergency drill log per health and safety code. Proof must be submitted to LPA via email by 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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 05/02/2023
NARRATIVE
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Resident Bedrooms 1 - 4: All contained the required furnishings, linens and were observed to be clean. Auditory devices located in resident rooms were not in “ON” position.

· Resident Bathrooms# 1-2: Were observed to contain soap, and paper towels. Signs promoting handwashing were observed. Water temperature in bathrooms were within the required 105 – 120 degrees F. Grab bars observed near toilet and showers. Showers and bathroom floors were observed to contain caked dirt and grime. Toilet bowls in both bathrooms were observed to contain dirt and yellowish stains around the rim of the toilet bowl. LPA observed one (1) walker and two (2) folding commodes being stored in resident bathroom #2. Bathroom sink in shared resident bathroom was observed to contain a white build up around the sink knobs.

· Centrally Stored Medications: LPA observed medications cabinet located in dining room area to be inaccessible to residents in care. LPA was unable to review resident Medication Administration Records (MAR) and prescribed medications due to facility not recording dosages for the month of May 2023.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. LPA could not verify last emergency drill due to facility not documenting last drill. LPA reviewed staff files and resident files.

Deficiencies are being cited during visit. Exit interview was conducted and a copy of this report and appeals rights was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
LIC809 (FAS) - (06/04)
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