A + Sincere Care Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Hugh He arrived a short time later. And assisted with the visit. LPA observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. 2. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved. A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place. Liability Insurance in the amount of at least ($1,000,000) occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2026. 3. Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood consisting of 6 bedrooms; 5 bedrooms for residents (4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room/ dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and home has no garage. The facility has one (1) fully charged fire extinguisher that was inspected on 01/25/2025. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature measured between 113.2 – 117.1 The shower sill in by the window needs to be cleaned. Refrigerator and freezer were unclean. 4.Staffing: A total of 3 caregiver staff provide care and supervision to the residents and are all over 18 years of age. (CONTINUED ON 809C) (continued from 809) 5. Personnel Records/Staff Training: Administrator certificates expire 8/06/2027. Personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training were checked. 6. Resident Records/Incident Reports: A total of four (4) resident files were reviewed. Files contained admission agreements that had monthly fee redacted. Physician's Reports for 2 residents needs to be updated., Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway. 7. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. 8. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables supplies are not sufficient. 9.Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed. All four files reviewed had PRN without orders and labels. Medical and dental transportation is provided by family, transportation services, or staff. 10. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was conducted on 02/09/2026. Need to update with second location away from facility. 11. Residents with Special Health Needs: One resident is receiving home health services. One resident is enrolled in hospice care. Individual Service Plans and Appraisals were observed in resident files. Deficiencies noted, technical violations issued Exit interview was conducted with Administrator Hugh He. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 30, 2026

The state marks this report as 10 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Hugh He arrived later. The following 12 (CARE) tool domains were utilized during the inspection: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. 2. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved. A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place. Liability Insurance in the amount of at least ($1,000,000)/ occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2025 A surety bond is not applicable. Facility does not handle resident's money. 3. Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood consisting of 6 bedrooms; 5 bedrooms for residents (4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room/ dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and home has no garage. The facility has one (1) fully charged fire extinguisher 01/15/2025. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were locked. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature in bathrooms was 119.7, 118.4, 118.9 and kitchen was 119.3 Deg F. 4.Staffing: A total of 3 caregiver staff provides care and supervision to the clients. Due to printer issues, report will be emailed. CONTINUED ON 809C...... 5. Personnel Records/Staff Training: Administrator certificates expire 8/06/2025. Personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was checked. 6. Resident Records/Incident Reports: A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. However, Dementia residents (R2- R4) had Physician Reports. RCFE complaint poster and Personal rights were observed posted in the facility hallway. 7. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. 8. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are in place. 9.Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed. Resident (R1) observed to have a 30-day supply of medications. Medical and dental transportation is provided by family, transportation services, or staff. 10. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was conducted on 1/13/2025. 11. Residents with Special Health Needs :One resident is receiving home health services. One resident is enrolled in hospice care. Individual Service Plans and Appraisals were observed in resident files. Resident has a G-tube and is enrolled in home health care and health care plan was observed on file. Exit interview was conducted with Administrator Hugh He. A copy of the report was issued. LPA Vaid having printer issues, will email this report to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Tao made an unannounced case management visit regarding a self-reported incident on the relocation of five (5) residents from Ace Senior Care Manor, Inc from Pasadena (license # 197607681, located at 940 N Lake Avenue, Pasadena, CA 91004) to A+ Sincere Care Manor (license # 197607431) due to the mandatory evacuation orders from Fire Advisory. LPA met with Hugh He, licensee/ administrator of Ace Senior Care Manor from Pasadena and A+ Sincere Care Manor from Temple City and explained the purpose of the visit. During the visit, LPA Tao conducted a health and safety check and no concerns observed. LPA residents/staff rosters for both facilities were obtained. Per the interview with administrator He, five (5) residents from Ace Senior Care Manor have been relocated to A+ Sincere Care Manor and one (1) resident went home with family. The current location has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. Residents’ rooms and bathrooms are in compliance with the required furnishing. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications, MARs, and staff/residents files have been transferred to A+ Sincere Care Manor facility and stored in the locked cabinets. Hugh Le is the licensee of both facilities. Both facilities use the same vendors, pharmacy, and provide the same level of care to residents. There is sufficient staffing available to provide care for residents at the facility. Hugh He, licensee confirmed all residents’ families/ responsible parties have been notified about the relocation to the current facility, either via calls, texts, or emails. No issues are observed during the visit. An exit interview was conducted and a copy of this report was provided to Hugh He.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sanjay Vaid initiated a case management visit to follow-up on the death of Client #1(C1). At 850 am Yameni Cota and Tony Qiu were present at the facility, contracted administrator via phone. Administrator FengPie Qin arrived shortly after to conduct case management visit. Facility completed death report for C1 dated 06/11/2024. C1 passed away at USC Arcadia Hospital. According to the report, C1 was diagnosed with advanced dementia, as per heath records. C1 was bedbound and unable to mobilize independently. After declining heath C1 was placed in hospice. C1 suffered from severe dementia since 12/15/2023. C1 was under physician’s care for Alzheimer’s Disease and HTN. The official cause of death is Alzheimer’s disease. LPA conducted a tour of the facility with Yameni Cota . The facility is a single story home located in a residential neighborhood consisting of 6 bedrooms; 5 for residents [4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and no garage. LPA observed sharps, toxins and medications under lock and inaccessible to clients. There were no health and safety concerns at the time of the visit. The following documents were reviewed: LIC 624, Medical Assesment/Physicians report, Needs and services plan, emergency and ID form LIC 601, MARS for two months, recent medical records. Administrator is working with C1's family to obtain the Death Certificate. Exit interview was held and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Fengpei "Pearl" Qin and Operations Manager arrived later. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved. A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2024. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood consisting of 6 bedrooms; 5 for residents [4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and no garage. The facility has one (1) fully charged fire extinguisher. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were locked. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature in bathrooms was 141.0, 143.6, 143.2, and kitchen was 143.3 DF. Citation was issued. Staffing: A total of 3 caregiver staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificates expires 8/16/2025. Personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was checked. Staff (S1- S3) have expired 1st Aid/CPR certificates. A citation was issued. Resident Records/Incident Reports: A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. However, Dementia residents (R2- R4) had Physician Reports that were dated 2021 & 2022. RCFE complaint poster and Personal rights were observed posted in the facility hallway. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are in place. Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed. Resident (R1) observed to have a 30-day supply of medications. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was conducted on 1/12/2024. Residents with Special Health Needs One (1) resident is receiving home health services. No residents are enrolled in hospice care. All resident beds had full rails, but none of the residents are enrolled in hospice care. Citation was issued. Individual Service Plans and Appraisals were observed in resident files. Resident (R3) has a G-tube and is not enrolled in home health care and no health care plan was observed on file. Citation was issued. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Fengpei "Pearl" Qin. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 12, 2024

The state marks this report as 17 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.