197607681-7-13-2023-28-AS-FFIS-CY7TM5-20231204135030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607681
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:48:49 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230705154738

FACILITY NAME:	ACE SENIOR CARE MANOR, INC.		FACILITY NUMBER:	197607681
ADMINISTRATOR:	PEARL HE		FACILITY TYPE:	740
ADDRESS:	940 N. LAKE AVE.		TELEPHONE:	(626) 398-2098
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	6	CENSUS: 5	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Hugh He		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Medications are accessible to residents in care.
Knives are accessible to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced compliant visit on 07/13/2023 at 09:15 am. LPA was met by caregiver Hengcai Sun/ Staff #1 (S1) at 9:15am and explained the purpose of the visit. At 11:30am, Administrator Hugh He arrived to assist with todays visit.

During todays visit the following was observed/conducted/collected: LPA requested and obtained a copy of staff and resident roster via email. LPA conducted a tour in all 3 units. First unit toured was Unit 944 LPA conducted a tour with Staff #2 (S2). Unit 942 was toured next by LPA and alongside Hengcai. Unit 940 last building to be toured was toured by LPA alongside with Staff #3 (S3). All three buildings have kitchen, bathroom, living room and residents rooms. At 11:45am Operation Manager Sophia Chan arrived to assist with the visit.

Continuation on 9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230705154738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ACE SENIOR CARE MANOR, INC.	FACILITY NUMBER: 197607681
	VISIT DATE: 07/13/2023

NARRATIVE

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Regarding allegation: Medications are accessible to residents in care. During today's visit LPA observed: Unit 940 all cabinets for medications were securely locked and inaccessible to resident in care, only 1 resident resides in this unit. Unit 942 medication cabinet in hallway 2 drawers for 2 residents medications were observed unlocked, pad locks latched on cabinet door but not securely closed. At 9:34am,Unit 944 medication cabinet 2 drawers for 2 residents were observed with padlock left open and not securely closed. At 11:26am LPA found Staff #4 medication bottle containing pills on table stand under living room TV. LPA interviewed Administrator who stated those are a staff medication, Hugh removed medication from facility. LPA interviewed S1 and S2 stated leaving medication cabinet closed with attached padlock but not securely locking padluck shut closed. S1 stated not securely locking of pad locks for knives when continuing to their next task. S2 stated not knowing code for code padlock for medication cabinets therefore leaves it padlock open. LPA attempt to interview all 5 residents in care , there was language barrier and/ or residents had dementia and/or were found sleeping. LPA observed Administrator Hugh telling S2 the passcode for padlocks for medication cabinets. Based on staff interviews and observation allegation is deem to be substantiated.

Regarding allegation: Knives are accessible to residents in care. During today's visit LPA observed: Unit 940 cabinets for knives were securely locked and inaccessible to client(s). At 9:44am Unit 942 knife cabinet in kitchen padlocks were observed unlocked, pad locks latched but not securely shut closed. At 9:15am Unit 944 knife cabinet in kitchen were observed with padlock left open and not securely closed. LPA interviewed staff: S1 stated not securely locking of pad locks for knives when continuing to their next task. S2 stated not knowing where key is for padlock for knife cabinet. LPA observed Administrator Hugh telling S2 where key was located for knife cabinet. LPA attempt to interview all 5 residents in care , there was language barrier and/or residents had dementia and/or were found sleeping. Based on staff interviews and observation allegation is deem to be substantiated.

Deficiencies were issued on 9099-D and Civil Penalties for Repeat Deficiencies were distributed for the two allegations listed above.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to Administrator Hugh He.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230705154738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ACE SENIOR CARE MANOR, INC.	FACILITY NUMBER: 197607681
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/14/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	(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.	1 2 3 4 5 6 7	Facility Administrator immedeatly removed staff medication out of facility premisis and locked all cabinets, instructing staff were to find keys and what the code is for padlocks were.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Unit 942 and 944 medication cabinet in hallways were observed unlocked, pad locks latched on cabinet door but not securely shut closed.LPA found Staff #4 medication bottle containing pills on table stand under living room TV. Based on LPA observation the licensee did not comply with the section cited above resulting in 5 out of 5 residents, which poses an immediate helath, safety or personal rifhts risk to residents in care.	8 9 10 11 12 13 14	Facility Administartor will provide all staff locker for each unit for personal belongings by date 7/31/23 . Facility Administrator will provide an in-service training on Regulation 87465 Incidental Medical and Dental Care and provide proof to LPA by date 7/31/23.
Type A 07/14/2023 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	Facility Administartor 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 regulation 87309 Storage Space and how to safe guard these items and send proof of training by 7/31/23. Admin. shut padlocks and provided staff with insturctions on where to locate padlock key and provide passcode to staff in unit 944.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above in 5 out of 5 residents. LPA observed at Unit 942 and 944 Unit, having knife cabinets in kitchen padlocks observed unlocked, pad locks latched but not securely shut closed. Observations poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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