197608491-8-22-2024-31-AS-NRED-D8DQ66-20240822115301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608491
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:53:32 AM

Document Has Been Signed on 08/22/2024 11:53 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
WOODLAND HILLS S.ASC, 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:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elaine Bote		TIME COMPLETED:	12:00 PM

NARRATIVE

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At approximately 9:00 a.m. on 08/22/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and S1 toured the facility inside and out.

The facility was last visited on 09/14/22 for an annual visit. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas.

The front entrance is gated and unlocked. Seating areas were observed at the front and rear of the facility. At the front door, LPA observed postings for the house rules, facility sketch, administrator certificate, facility license, emergency disaster plan, COVID precautions, personal rights, theft and loss policy, rights of resident councils, confidential complaint contacts, ombudsman contacts, and oxygen in use signs. A screening station at the front contained a visitor log, sanitizer, and masks.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:20 a.m. LPA measured the room temperature to be 78 degrees Fahrenheit. The living room contained a television, reading materials, and furniture in good repair. At 9:30 a.m. the house telephone was called and deemed operational.

The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Residents with half-bedrails had prescriptions in their facility files. Exit doors from rooms were unlocked. All auditory alarms were tested and functioning. Ramps leading out were secure, and emergency exit paths were free of debris or hazards.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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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Document Has Been Signed on 08/22/2024 11:53 AM - 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one (01) out of five (05) not being tested for tuberculosis which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2024
	Plan of Correction
1 2 3 4	Licensee will arrange for a TB test for the resident and submit proof of negative test 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 11:53 AM - 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four (04) out of five (05) residents having incomplete records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to have all residents and responsible parties sign the incomplete paperwork and submit proof 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
	VISIT DATE: 08/22/2024

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The seating area in the rear was shaded. The back yard also contained a gardened area and an unlocked exit gate. The storage shed was locked and contained tools and chemical cleaners.

A separate living area contained a piano and a treadmill. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer as well as the garage and garage refrigerator. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and confidential files were locked in separate cabinets. The garage was unlocked and contained a washing machine, a dryer, and extra supplies. Both appliances were in working order. Detergents were locked above them in a cabinet.

The facility has four (04) bathrooms. One (01) bathroom is private, and three (03) are shared. All bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:15 a.m. LPA measured the water temperature to be 105.1 degrees Fahrenheit in the shared bathroom.

At approximately 10:20 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 10:25 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 09/18/23.

At 10:40 a.m. LPA conducted a records review of resident and personnel files. Most files were complete and available for audit. During record review, it was discovered that four (04) out of five (05) residents had incomplete consent forms and property and valuable forms. Deficiency is issued on the corresponding LIC 809-D page. Additionally, Resident #1 (R1) did not have a test for Tuberculosis in their file. Interview with S1 at 11:20 a.m. revealed R1 was not tested for Tuberculosis. Deficiency is issued on the corresponding LIC 809-D page

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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