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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607431
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:55:40 PM

Document Has Been Signed on 03/12/2024 03:55 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
CCLD Regional Office, 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: 4DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Fengpei "Pearl" Qin, Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Fengpei "Pearl" Qin and Operations Manager arrived later. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved.
  • A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2024. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood consisting of 6 bedrooms; 5 for residents [4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and no garage. The facility has one (1) fully charged fire extinguisher.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were locked.
  • Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature in bathrooms was 141.0, 143.6, 143.2, and kitchen was 143.3 DF. Citation was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A + SINCERE CARE MANOR
FACILITY NUMBER: 197607431
VISIT DATE: 03/12/2024
NARRATIVE
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Staffing:
  • A total of 3 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expires 8/16/2025.
  • Personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was checked. Staff (S1- S3) have expired 1st Aid/CPR certificates. A citation was issued.

Resident Records/Incident Reports:
  • A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. However, Dementia residents (R2- R4) had Physician Reports that were dated 2021 & 2022.
  • RCFE complaint poster and Personal rights were observed posted in the facility hallway.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are in place.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A + SINCERE CARE MANOR
FACILITY NUMBER: 197607431
VISIT DATE: 03/12/2024
NARRATIVE
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Incident Medical and Dental:
  • Four (4) centrally stored resident medications were reviewed. Resident (R1) observed to have a 30-day supply of medications.
  • Medical and dental transportation is provided by family, transportation services, or staff.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last emergency disaster drill was conducted on 1/12/2024.

Residents with Special Health Needs
  • One (1) resident is receiving home health services. No residents are enrolled in hospice care.
  • All resident beds had full rails, but none of the residents are enrolled in hospice care. Citation was issued.
  • Individual Service Plans and Appraisals were observed in resident files.
  • Resident (R3) has a G-tube and is not enrolled in home health care and no health care plan was observed on file. Citation was issued.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Fengpei "Pearl" Qin. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 12 of 17
Document Has Been Signed on 03/12/2024 03:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/12/2024 at 02:45 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
PERSONNEL REQUIREMENTS - GENERAL
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1-S3 ) did not have current 1st Aid/CPR training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Submit a copy of S1-S3's 1st Aid/CPR training card.
Type B
Section Cited
CCR
87615(a)(2)
Prohibited Health Conditions
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Gastrostomy tubes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in that resident (3) has a g-tube but is not receiving home health services, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Administrator shall submit an Exception Request 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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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Page: 13 of 17
Document Has Been Signed on 03/12/2024 03:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/12/2024 at 02:51 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: 03/12/2024

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, the licensee did not comply with the section cited above in that the hot water in bathrooms was 141.0, 143.6, 143.2, and kitchen was 143.3 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Admininstrator adjusted the hot water temperature during the visit. Submit a hot water temperature log showing that the water was tested 3x today and 3x tomorrow.
Section Cited
Incidental Medical and Dental Care Services
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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Page: 14 of 17
Document Has Been Signed on 03/12/2024 03:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/12/2024 at 02:51 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
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: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Resident (R1) is missing Crestor Oral Tablet 5 mg, Levetiracetam 500 mg, amino acids 30 ml, Ciclopirox 8% sol, Ranolazine 500 mg, and the facility had Rx- Levothyroxine Sodium 25 mcg (dosage error), instead of 150 mg, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator shall fill all missing medications immediately and submit POC proof by tomorrow. Additionally, all staff shall be re-trained on regulation 87465.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that all residents (R1-R4) had full bed-rails without being enrolled in hospice services, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator shall remove all full bed-rails from resident beds and request physician orders for half bed rails. Submit pictures of beds with installed half bed-rails and copies of their physician's orders. Administrator requested an extra day because 1 MD is on vacation.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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Document Has Been Signed on 03/12/2024 03:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/12/2024 at 02:51 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: 03/12/2024

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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2
3
4
Based on observation, the licensee did not comply with the section cited above in that underneath 2 bathroom sinks Lysol spray, furniture polish, and bengay ointment were observed unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator shall remove all toxic substances that are stored in unlocked bathroom cabinets and submit written certification of how the deficiency was corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 16 of 17
Document Has Been Signed on 03/12/2024 03:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/12/2024 at 02:51 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that resident (R4) has an oxygen tank in the room and "No Smoking- Oxygen in Use “signage was not posted anywhere in the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Submit a picture of the posted "No Smoking- Oxygen in Use “ sign.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that residents (R2 - R4) have Physician Reports more than 1 year old dated (2021 & 2022), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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2
3
4
Submit copies of updated Phyician's Reports for residents (R2-R4).
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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