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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608491
Report Date:
09/09/2021
Date Signed:
09/13/2021 01:58:27 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ACE SENIOR CARE
FACILITY NUMBER:
197608491
ADMINISTRATOR:
ELAINE BOTE
FACILITY TYPE:
740
ADDRESS:
22910 SHERMAN WAY
TELEPHONE:
(818) 914-5002
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91307
CAPACITY:
6
CENSUS:
3
DATE:
09/09/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Elaine Bote
TIME COMPLETED:
11:22 AM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA met with administrator Elaine Bote. Upon entry to the facility LPAs' temperature and Covid screening were chcked. All COVID signs were posted throughout the facility. Administrator was given the purpose of the visit.
The signs for Covid 19 awareness were posted. throughout the facility and updated as well. LPA requested a copy of the mitigation plan and administrator states she did get resubmit a mitigation plan on 6-7-21. It would have been the 3rd time she submitted. She never heard back. LPA will check in the office for copy of mitigation plan. She had the mitigation plan with approval printed during this visit. A copy was given to LPA.
LPA observed there was a PPE supply for 6 months. All resident rooms had hand sanitizer and appeared clean and organized. Surfaces and bathrooms are cleaned regularly. Medication supply is in stock for 30 days for each resident. Social distancing is practiced for visitation in patio area and face time. Staff and Residents are all vaccinated. Surveillance testing for the staff is done regularly.
A brief tour of the facility was taken and each residents room had hand sanitizer and tissue. All residents appeared well groomed.
Facility is in compliance with title 22 at this time. No citations issued. Exit interview conducted.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Angelica Arambulo
TELEPHONE:
(818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE:
09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/09/2021
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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