<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607681
Report Date: 04/04/2023
Date Signed: 04/04/2023 09:43:00 PM


Document Has Been Signed on 04/04/2023 09:43 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:ACE SENIOR CARE MANOR, INC.FACILITY NUMBER:
197607681
ADMINISTRATOR:PEARL HEFACILITY TYPE:
740
ADDRESS:940 N. LAKE AVE.TELEPHONE:
(626) 398-2098
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 6DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Staff S1TIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/04/2023 at 09:15 am. LPA was met by Staff# 1 (S1) and explained the purpose of the visit. Facility is licensed to residents over 60 years old and is currently approved for five (5) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 09:42 am and was led by LPA due to no designation of facility responsibility. According to S1 Administrator Pearl He is out of the country and neither S1 nor LPA could locate LIC 308 (Designation of Facility Responsibility form). At 10:20 am, Staff #2 (S2) arrived to assist with the remaining tour. The Facility is divided into three (3) units and located in a main street. Each unit contains 2 resident bedrooms, 1 shared full resident bathroom, hand washing station, kitchen, living room, dining room, and linen closet.

UNIT 940

LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed files, boxes, bags filled with various items in the corner of the room. LPA observed a mattress and folding bed frame behind couch. At 12:55 pm, when LPA was returning to unit 940 to gather briefcase, LPA observed R3 sitting in a wheelchair, undressed from the waist down, in a common area.

KITCHEN: Water temperature in kitchen was measured at 122.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. LPA observed dirt, litter, and crumbs in kitchen cabinet, that contained spices. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Kitchen appliances were observed to contain caked on spatter and were sticky to the touch.

HAND WASHING STATION: Water temperature was measured at 123.0 degrees F, which is not within the required 105 – 120 degrees F. LPA observed toilet bowl disinfectant in cabinet located directly under sink, which was accessible to 2 out of 2 residents in care. LPA observed a pair of scissors in a plastic cup behind hand washing station, which was accessible to 2 clients.

RESIDENT BEDROOMS 1-2: All contained the required furnishings, linen, and lighting as required.

SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measure at 126.5 degrees F.

Dining room: LPA observed serval bags in various items on dining room table. LPA observed two (2) chairs near table. LPA observed PPE supplies, and adult hygiene products stacked in corner of dining area.

CENTRALLY STORED MEDICATIONS: LPA reviewed medications for 2 residents in this unit.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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 8


Document Has Been Signed on 04/04/2023 09:43 PM - It Cannot Be Edited

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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee will lower water heater by 04/05/23. Licensee will create a water log and record water temperature, every 24hrs for the next 7 calendar days. Proof must be submitted to LPA by 4-11-23 via email.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
1
2
3
4
Licensee will place a sign above kitchen sinks with warning signs " WATER TEMPERATURE MAY DELIVER ABOVE 125 DEGREES F."
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8


Document Has Been Signed on 04/04/2023 09:43 PM - It Cannot Be Edited

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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
1
2
3
4
Licensee will ensure all 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. Licensee must re-train staff on how to safe guard these items and send proof of training and receipt of staff receiving training. Staff removed items while LPA was present and placed in location inaccessible to residents.
Type A
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
1
2
3
4
Licensee will ensure LIC 308 is on file in lieu of absence. LPA must recieve no later than 04/05/23 via email.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 04/04/2023 09:43 PM - It Cannot Be Edited

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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
1
2
3
4
Licensee will retrain staff on safe guarding of medications and only allow direct access others persons other than employees resonpsible for the supervision of the centrally stored medication.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
1
2
3
4
Licensee will retrain staff on how to properly record medication dosage and submitt proof to LPA.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 04/04/2023 09:43 PM - It Cannot Be Edited

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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
 Staff will remove all clutter from dining areas and living room area. Photo proof must be submitted to LPA.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 6out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee will clean kitchen floors and bathrooms floors. Photo proof must be submitted to LPA
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 04/04/2023 09:43 PM - It Cannot Be Edited

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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee will remove all extra hygiene products in common areas and move to proper storage area. Photo proof required.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee will store such items away from food supplies. Photo proof of correction required.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681
VISIT DATE: 04/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
UNIT 942

LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed a table with various folders and papers piled up in a nearby corner.

KITCHEN: Water temperature in kitchen was measured at 135.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Sufficient supply of perishables and non-perishables was observed.

HAND WASHING STATION: Water temperature was measured at 140.0 degrees F, which is not within the required 105 – 120 degrees F. LPA observed a pair of scissors in a cup behind hand washing station.

RESIDENT BEDROOMS 3-4: All contained the required furnishings, linen, and lighting as required.

SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measured at 138.2 degrees F.

DINING ROOM: LPA observed serval bags and papers located on table. Not enough seating for residents and visitors was observed.

CENTRALLY STORED MEDICATIONS: LPA observed C3’s spouse access C3’s open medication cabinet that staff opened at their request. C3’s spouse began to divide medications in holders and place back in medication cabinet.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: ACE SENIOR CARE MANOR, INC.
FACILITY NUMBER: 197607681
VISIT DATE: 04/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
UNIT 944

LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed a table with various folders and papers piled up in a nearby corner.

KITCHEN: Water temperature in kitchen was measured at 155.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Sufficient supply of perishables and non-perishables was observed. Disinfectant sprays were observed under kitchen sink and accessible to 2 clients in care. LPA observed stove knob to be held in place by black tape. Appliances were observed to be dirty and sticky to touch.

HAND WASHING STATION: Water temperature was measured at 147.9 degrees F, which is not within the required 105 – 120 degrees F. LPA observed a pair of scissors in a cup behind hand washing station.

RESIDENT BEDROOMS 5-6: All contained the required furnishings, linen, and lighting as required.

SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measured at 154.5 degrees F.

DINING ROOM: LPA observed serval bags and papers located on table. Not enough seating for residents and visitors was observed. LPA observed a bottle of tide laundry soap next to food items on a near by shelf. LPA observed a bottle of wound care next to bananas.

CENTRALLY STORED MEDICATIONS: LPA observed R1 and R2 received medications but staff did not record dosage accurately.

Deficiencies are being cited. Exit interview conducted with S2, and LIC 809, LIC 809-C, LIC 809-D, and appeals rights will be emailed due to printer problems.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8