197608491-9-14-2022-31-AS-NRED-CJ9UYU-20220914160031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608491
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:00:40 PM

Document Has Been Signed on 09/14/2022 04:00 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, 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: 5	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Elaine Bote		TIME COMPLETED:	04:12 PM

NARRATIVE

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At 2:00 p.m. on 09/14/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 09/09/2021 for an annual visit. It is a single story building with 6 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 6 may be bedridden. The facility uses a sprinkler system for fire safety. The facility serves residents with dementia. Approved hospice waivers for 2.

Two signs were posted at the main entrance. One sign showed facility’s visitation policy and the other showed “No smoking – Oxygen in use”. Postings in the interior included Ombudsman contacts, confidential complaint contact, Administrator certificate, facility license, resident rights, facility sketch, and Emergency Disaster Plan. LPA was screened for infectious disease upon entry. The screening station contained two digital thermometers, N95 masks, hand sanitizer, face shields, and a visitor log. The visitor log included symptom checklists which tracked name, phone number, symptoms, temperature, and vaccination status.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The living room contained workout equipment, magazines, and social-distanced furniture. At approximately 2:20 p.m. LPA measured the living room temperature to be 78 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable food. The stove hood was clean. All appliances were functional and sanitary. Sharps were locked under the counter top. At approximately 2:25 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/10/2022. The garage contained an operable washer and dryer, an extra refrigerator, and extra supplies. Cleaning solutions and paints were locked above the washer and dryer.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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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Document Has Been Signed on 09/14/2022 04:00 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)(1)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:(1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 residents on hospice, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit a hospice waiver increase request to LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
	VISIT DATE: 09/14/2022

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The facility had 6 bedrooms, all of which were private. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. At approximately 2:25 p.m. LPA observed 3 out of 6 bedrooms contained beds with full bedrails. Staff confirmed all residents had physician’s orders for the bed rails. File review showed the facility only has hospice waivers for 2 residents. Administrator stated a waiver increase was requested. The deficiency is cited on the attached LIC 809-D page.

The facility had 2 bathrooms. Both bathrooms contained liquid soap, paper towels, handwashing instruction signs, trash cans with tight fitting lids, grab bars near the toilet and shower, assistive devices, and a non-skid mat in each shower. At 3:03 p.m. LPA measured the water in Bathroom #2 to be 105.9 degrees Fahrenheit.

All emergency exit paths were free from obstructions. Exit gates were unlocked. At 2:31 p.m. LPA tested the smoke detector to be operational. At 3:47 p.m. LPA tested the carbon monoxide detector to be operational. All auditory alarms were on and functioning.

The back yard was maintained and had a garden and covered patio furniture in good repair.

Exit interview conducted. Copy of report, appeal rights, and citation issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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