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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607431
Report Date: 06/17/2024
Date Signed: 06/17/2024 09:33:21 AM


Document Has Been Signed on 06/17/2024 09:33 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
MONTEREY PARK ASC, 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:
06/17/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:FengPei Qin, AdministratorTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Sanjay Vaid initiated a case management visit to follow-up on the death of Client #1(C1). At 850 am Yameni Cota and Tony Qiu were present at the facility, contracted administrator via phone. Administrator FengPie Qin arrived shortly after to conduct case management visit.

Facility completed death report for C1 dated 06/11/2024. C1 passed away at USC Arcadia Hospital. According to the report, C1 was diagnosed with advanced dementia, as per heath records. C1 was bedbound and unable to mobilize independently. After declining heath C1 was placed in hospice. C1 suffered from severe dementia since 12/15/2023. C1 was under physician’s care for Alzheimer’s Disease and HTN. The official cause of death is Alzheimer’s disease.

LPA conducted a tour of the facility with Yameni Cota . 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. LPA observed sharps, toxins and medications under lock and inaccessible to clients. There were no health and safety concerns at the time of the visit.

The following documents were reviewed: LIC 624, Medical Assesment/Physicians report, Needs and services plan, emergency and ID form LIC 601, MARS for two months, recent medical records.

Administrator is working with C1's family to obtain the Death Certificate. Exit interview was held and a copy of the report was provided to the facility.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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