Ace Senior Care Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Hugh He, Administrator, and the reason for the visit was explained. The facility is licensed to serve (1) bedridden and (5) non-ambulatory residents age 60 and above. Bedridden approval is granted to any room with direct exit, not to exceed (1) bedridden resident. Hospice waiver is approved for (1) resident, approval for front unit only. There are currently (4) residents living in the facility. The facility consists of the following: The property has (3) separate units. Each unit has a living room, dining area, kitchen, (2) resident bedrooms, (1) bathroom and (1) staff break room. The property also has a front and backyard and a detached garage with a laundry area and storage unit. LPA observed the following during today’s visit: The facility was observed clean inside and out. Walkways, passageways, ramps and exits are kept clear of debris and obstructions. Furniture throughout the facility kept is clean and in good repair. The kitchens were observed clean and appliances were operating properly. The facility has a sufficient 2-day perishable and 7-day perishable supply of food in each unit. Resident bedrooms have the required furniture, bedding and sufficient lighting. Bathrooms were observed clean and sanitary and the water temperature measured within compliance range of 105 – 120 degrees F. Front and backyard are kept clean. No pools or bodies of water were observed. The laundry area is kept clean, and appliances are in operating condition. The garage was observed free of clutter. ***Continues on LIC 809-C*** The homes have (3) fire extinguishers which is kept charged and operable. Interconnected smoke detectors were tested during visit and were operating properly. Carbon monoxide detectors were also tested and were working properly. The facility conducts safety drills every month. Last safety drill was conducted on 3/6/2026. Medications are centrally stored in the kitchens and were observed to be dispensed according to physician orders and documented accordingly. Four (4) resident and (4) staff files were reviewed. Staff files contain mandated documents including training certificates and criminal background clearances and associations. Resident files contain relevant documentation including bed rail physician orders for (3) residents and Home Health Care Plan for (1) resident. The facility has current liability insurance. No deficiencies noted and no citations issued today. Exit interview was conducted with Hugh He, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced site visit for the required annual inspection. Upon arrival at the facility, LPA met with Staff, Linda King, who assisted with the visit. Administrator, Hugh He, arrived shortly thereafter to join the inspection. The facility is licensed to serve a total of six (6) residents, one may be bedridden and 5 non-ambulatory ages 60 and above. The hospice waiver is approved for 1 resident. LPA utilized the infection control domain for the inspection and reviewed medications and food supplies, client and staff files. The facility consists of three (3) separate units on the same lot. Each unit consists of two (2) resident bedrooms, one (1) bathroom, living room, dining room, and kitchen. There are two (2) separate garages located in the back. There are no pools or bodies of water at the location. There are five (5) residents residing at the facility on today’s visit. During today's visit, LPA observed two residents, one bedridden resident in the front unit (940), one (1) residents residing in the middle unit (942), and 2 residents in the back unit (944). The facility has a sign in station with masks and hand sanitizers available at each of the unit. Covid-19 signage is posted at each of the units, hand washing signage in the bathrooms and kitchen. There were at least 30 days of PPE supplies in storage. Water temperature measured at 105-120 deg F. Disinfectants and cleaning solution are properly stored making them inaccessible to residents. Staff were observed wearing face masks. Two -day perishables and 7-day non-perishable were observed. LPA reviewed the medications for all five (5) residents. LPA reviewed three staff files. Administrator-Pearl He, certificate expires 08/06/2025, Hugh He certificate expires on 08/07/25. Both administrators are in process of renewing their certificates. Facility fees were paid on 05/29/25, LPA was provided proof with confirmation 969717. No deficiencies were observed on todays’, a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced site visit for the required annual inspection. Upon arrival at the facility, LPA met with Staff, Linda King, who assisted with the visit. Administrator, Hugh He, arrived shortly thereafter to join the inspection. The facility is licensed to serve a total of six (6) residents, one may be bedridden and 5 non-ambulatory ages 60 and above. The hospice waiver is approved for 1 resident. LPA utilized the infection control domain for the inspection and reviewed medications and food supplies. The facility consists of three (3) separate units on the same lot. Each unit consists of two (2) resident bedrooms, one (1) bathroom, living room, dining room, and kitchen. There are two (2) separate garages located in the back. There are no pools or bodies of water at the location. There are five (5) residents residing at the facility on today’s visit. During today's visit, LPA observed one bedridden resident in the front unit (940), no residents residing in the middle unit (942), and 2 residents in the back unit (944). The facility has a sign in station with masks and hand sanitizers available at each of the unit. Covid-19 signage is posted at each of the units, hand washing signage in the bathrooms and kitchen. There were at least 30 days of PPE supplies in storage. Disinfectants and cleaning solution are properly stored making them inaccessible to residents. Staff were observed wearing face masks. Two -day perishables and 7-day nonperishables were observed. LPA reviewed the medications for all five (5) residents. LPA reviewed three staff files. Administrator-Pearl He, certificate expires 08/06/2025, Hugh He certificate expires on 08/07/25. Both administrators are in process of renewing their certificates. No deficiencies were observed on todays’, a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction visit to follow up on deficiencies noted during annual visit conducted on 4/16/24 and 4/18/24. LPA met with Hongwei He and explained the reason for the visit. The following deficiencies were noted during the visit of 4/16/24 and 4/18/24: Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health conditions. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency was not cleared. On 5/7/24 LPA observed R1-R3 at the facility, reviewed physician's letter for R2 which notes R2 is no longer under a prohibited health condition. However, R1 and R3 continue to have a prohibited condition and reside at the facility. On 5/16/24 Administrator submitted an exception letter request for a prohibited health condition to the department. Deficiency cleared as of 5/21/24. Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for Resident #1(R1) which notes full bed rails however R1 is not on hospice. Physician' order for Resident #5 (R5) does not identify the type of rails that R5 may use. No other bed rails request were obtained. On 4/25/24 Deficiency was not cleared. On 4/26/24 bed rail request was submitted for resident #6(R6).On 5/7/24 LPA Flores observed full bed rails on R1's bed, resident is not on hospice. Licensee must either replace rails with half bed rails or request an exception for full bed rails to the department. Resident #3's (R3) bed rails were removed. Bed rail physician's request was submitted to the department on 5/1/24 for resident #2 (R2). No bed rail request were obtained for resident #4. Deficiency not cleared. On 5/21/24 LPA reviewed bed rail request for resident #4 and observed Resident #1's bed rail is a half bed rail. Deficiency cleared as of 5/21/24. (CONTINUED ON LIC 809C) Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. On 5/7/24 LPA Flores reviewed TB test for R6. No TB test for R5 was obtained. Deficiency not cleared. On 5/15/24 Administrator submitted a copy of TB test for R5 to the department. Deficiency cleared as of 5/15/24. No pending deficiencies to clear for annual visit conducted on 4/16/24 and 4/18/24. Exit interview was conducted with Hongwei He and a copy of this report and clearance letters were provided.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiencies noted on 4/16/24 and 4/18/24 during an annual visit. LPA met with Winnie Tran and explained the reason for the visit. On 4/25/24 LPA Flores conducted a POC visit to clear the deficiencies noted during the annual visit and the following deficiencies were not cleared, civil penalties were noted during the visit of 4/25/24: Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health conditions. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency was not cleared. On 5/7/24 LPA observed R1-R3 at the facility, reviewed physician's letter for R2 which notes R2 is no longer under a prohibited health condition. However, R1 and R3 continue to have a prohibited condition and reside at the facility. *Civil penalties were noted for failure to correct.* Type A - 87204(a) Limitations-Capacity and Ambulatory Status - On 4/18/24 During file review LPA observed 3 out of 6 residents are bedridden per physician's report. ON 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1,R2,Resident #4(R4) ambulatory status. R1,R2, R4 were observed at the facility at the time of the visit. On 4/25/24 Deficiency was not cleared. On 5/1/24 administrator submitted to the department physician's letters for R2 and R4, which describes residents ambulatory status as non-ambulatory and not bedridden. Facility is licensed to have 1 bedridden resident. Therefore, deficiency is cleared as of 5/1/24. Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for Resident #1(R1) which notes full bed rails however R1 is not on hospice. (CONTINUED ON LIC 809C) Physician' order for Resident #5 (R5) does not identify the type of rails that R5 may use. No other bed rails request were obtained. On 4/25/24 Deficiency was not cleared. On 4/26/24 bed rail request was submitted for resident #6(R6).On 5/7/24 LPA Flores observed full bed rails on R1's bed, resident is not on hospice. Licensee must either replace rails with half bed rails or request an exception for full bed rails to the department. Resident #3's (R3) bed rails were removed. Bed rail physician's request was submitted to the department on 5/1/24 for resident #2 (R2). No bed rail request were obtained for resident #4. Deficiency not cleared. *Civil Penalties were noted for failure to correct.* Type A - 87309(a) Storage Space - On 4/16/24 LPA observed kitchen in unit #2 had cleaning solution in a cabinet without a lock, cabinet under sink located in the hallway had disinfectant spray without a lock, and mirror cabinet in unit #2 and #3 had cleaning powder in a plastic bottle. On 4/25/24 LPA observed detergent in can and half plastic bottle in mirror cabinet in outside sink in unit #2 and can with detergent in mirror cabinet in bathroom of unit #3. On 4/25/24 Deficiency was not cleared. On 5/7/24 LPA toured the facility and observed cleaning supplies and solutions were under locked. Deficiency cleared as of 5/7/24. Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. On 5/7/24 LPA Flores reviewed TB test for R6. No TB test for R5 was obtained. Deficiency not cleared. Civil Penalties were noted for failure to correct.* Exit interview was conducted with Hongwei He and a copy of this report, civil penalties, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted a visit to provide corrected plan of correction (POC) visit version for report provided on visit conducted on 4/25/24. LPA met with Checksim Lim and explained the reason for the visit. On 4/25/24 LPA Flores conducted a plan of correction visit and noted under Type B - 87458(b)(1) Medical Assessment - civil penalties were noted in error. Therefore, LPA is creating today's report to correct that. On 4/16/24 and 4/18/24 LPA noted the following Type A/B deficiencies during the annual visit: Type A - 87307 Personal Accommodations and Services - 1 out of 6 residents bedroom, room #6 is being used by a resident and a staff. On 4/25/24 LPA Flores observed the bed was removed and a chair was provided. Deficiency cleared as of 4/25/24. Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health condition. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency not cleared.*Civil Penalties will be noted today for failure to correct.* Type A - 87204(a) Limitations-Capacity and Ambulatory Status - On 4/18/24 During file review LPA observed 3 out of 6 residents are bedridden per physician's report. ON 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1,R2,Resident #4(R4) ambulatory status. R1,R2, R4 were observed at the facility at the time of the visit. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* (CONTINUED ON LIC 809C) Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for R1 which notes full bed rails however R1 is not on hospice and physician' order for R5 does not identify the type of rails that R5 may use. No other bed rails request were obtained. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* Type A - 87303(e) (2) Maintenance and Operation - On 4/16/24 LPA tested water temperature in unit #2 tested at 120.9 degrees F., and in unit #3 water temperature tested at 138.2 degrees F. On 4/25/24 LPA Flores tested the water temperature in the bathrooms' in unit #2 and #3 and tested between 107-113.7 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 4/25/24. Type A - 87309(a) Storage Space - On 4/16/24 LPA observed kitchen in unit #2 had cleaning solution in a cabinet without a lock, cabinet under sink located in the hallway had disinfectant spray without a lock, and mirror cabinet in unit #2 and #3 had cleaning powder in a plastic bottle. On 4/25/24 LPA observed detergent in can and half plastic bottle in mirror cabinet in outside sink in unit #2 and can with detergent in mirror cabinet in bathroom of unit #3. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* Type A - 87355(d)(3) Criminal Record Clearance - On 4/16/24 LPA observed staff #1(S1) working at the facility and upon file review observed S1 did not have a background clearance. On 4/25/24 LPA reviewed Guardian list and Staff #1 is cleared and association as 4/17/24. Deficiency cleared as of 4/25/24. Type A - 87555(b)(26) General Food Services Requirements - On 4/16/24 LPA review each kitchen and garage and did not observed a variety of food supplies sufficient for 6 residents for at least 2 days of perishables and 7 days on non-perishables. On 4/25/24 LPA observed food supplies in each refrigerator sufficient for 2 days of perishables, and 7 days of non-perishables for 6 residents only. Deficiency cleared as of 4/25/24. Type A - 87465(h)(2) Incidental Medical and Dental Care Services - On 4/16/24 LPA observed medication for resident #6 (R6) was observed in the refrigerator accessible to the residents. On 4/25/24 LPA observed combination lock box for medication inside refrigerator. Deficiency cleared as of 4/25/24. (CONTINUED ON LIC 809C) Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. Type B - 1569.695(d) – Health and Safety Code - On 4/18/24 Emergency Disaster Plan was last reviewed on 8/30/22, plan does not meet the standards of current version LIC 610E(3/19). On 4/25/24 LPA reviewed a copy of LIC 610E(3/19). Deficiency cleared as of 4/25/24. Type B - 87705(c )(5) Care of Person with Dementia - On 4/18/24 LPA observed R6 last physician's report is dated 8/15/20. On 4/25/24 LPA reviewed physician's report for R6 dated 12/7/23. Deficiency cleared as of 4/25/24. Type B - 87303(a) Maintenance and Operation - On 4/16/24 LPAs observed buildup of soap and mold in each shower(3) and kitchen #2. On 4/25/24 LPA observed each shower and kitchen #2 which were observed clear of buildup and clean. Deficiency cleared as of 4/25/24. Type B - 87303 (e)(5) Maintenance and Operation - On 4/16/24 LPA observed that 3 out of 3 showers did not have a skid mat. On 4/25/24 LPA observed a skid mat in each shower. Deficiency cleared as of 4/25/24. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies noted during annual visit conducted on 4/16/24 and 4/18/24. LPA met with Winnie Tan and explained the reason for the visit. Hongwei He assistant administrator arrived 10 minutes later. On 4/16/24 and 4/18/24 LPA noted the following Type A/B deficiencies during the annual visit: Type A - 87307 Personal Accommodations and Services - 1 out of 6 residents bedroom, room #6 is being used by a resident and a staff. On 4/25/24 LPA Flores observed the bed was removed and a chair was provided. Deficiency cleared as of 4/25/24. Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health condition. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency not cleared.*Civil Penalties will be noted today for failure to correct.* Type A - 87204(a) Limitations-Capacity and Ambulatory Status - On 4/18/24 During file review LPA observed 3 out of 6 residents are bedridden per physician's report. ON 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1,R2,Resident #4(R4) ambulatory status. R1,R2, R4 were observed at the facility at the time of the visit. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for R1 which notes full bed rails however R1 is not on hospice and physician' order for R5 does not identify the type of rails that R5 may use. No other bed rails request were obtained. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* (CONTINUED ON LIC 809C) Type A - 87303(e) (2) Maintenance and Operation - On 4/16/24 LPA tested water temperature in unit #2 tested at 120.9 degrees F., and in unit #3 water temperature tested at 138.2 degrees F. On 4/25/24 LPA Flores tested the water temperature in the bathrooms' in unit #2 and #3 and tested between 107-113.7 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 4/25/24. Type A - 87309(a) Storage Space - On 4/16/24 LPA observed kitchen in unit #2 had cleaning solution in a cabinet without a lock, cabinet under sink located in the hallway had disinfectant spray without a lock, and mirror cabinet in unit #2 and #3 had cleaning powder in a plastic bottle. On 4/25/24 LPA observed detergent in can and half plastic bottle in mirror cabinet in outside sink in unit #2 and can with detergent in mirror cabinet in bathroom of unit #3. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* Type A - 87355(d)(3) Criminal Record Clearance - On 4/16/24 LPA observed staff #1(S1) working at the facility and upon file review observed S1 did not have a background clearance. On 4/25/24 LPA reviewed Guardian list and Staff #1 is cleared and association as 4/17/24. Deficiency cleared as of 4/25/24. Type A - 87555(b)(26) General Food Services Requirements - On 4/16/24 LPA review each kitchen and garage and did not observed a variety of food supplies sufficient for 6 residents for at least 2 days of perishables and 7 days on non-perishables. On 4/25/24 LPA observed food supplies in each refrigerator sufficient for 2 days of perishables, and 7 days of non-perishables for 6 residents only. Deficiency cleared as of 4/25/24. Type A - 87465(h)(2) Incidental Medical and Dental Care Services - On 4/16/24 LPA observed medication for resident #6 (R6) was observed in the refrigerator accessible to the residents. On 4/25/24 LPA observed combination lock box for medication inside refrigerator. Deficiency cleared as of 4/25/24. Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. *Civil Penalties will be noted today for failure to correct.* (CONTINUED ON LIC 809C) Type B - 1569.695(d) – Health and Safety Code - On 4/18/24 Emergency Disaster Plan was last reviewed on 8/30/22, plan does not meet the standards of current version LIC 610E(3/19). On 4/25/24 LPA reviewed a copy of LIC 610E(3/19). Deficiency cleared as of 4/25/24. Type B - 87705(c )(5) Care of Person with Dementia - On 4/18/24 LPA observed R6 last physician's report is dated 8/15/20. On 4/25/24 LPA reviewed physician's report for R6 dated 12/7/23. Deficiency cleared as of 4/25/24. Type B - 87303(a) Maintenance and Operation - On 4/16/24 LPAs observed buildup of soap and mold in each shower(3) and kitchen #2. On 4/25/24 LPA observed each shower and kitchen #2 which were observed clear of buildup and clean. Deficiency cleared as of 4/25/24. Type B - 87303 (e)(5) Maintenance and Operation - On 4/16/24 LPA observed that 3 out of 3 showers did not have a skid mat. On 4/25/24 LPA observed a skid mat in each shower. Deficiency cleared as of 4/25/24.the state’s words, verbatim · CDSS document, Apr 25, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted a continue unannounced annual visit at the facility using the inspection CARE tool. LPA met with Linda King and explained the reason for the visit. Assistant Administrator arrived 30 minutes later. During this visit LPA completed the following domains: Infection Control, Operational Requirements, Staffing Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Resident Records / Incident Reports, Disaster Preparedness, Residents with Special Health Needs. LPA Flores reviewed files for 5 residents, per file review Resident #1-#3(R1-R3) have a prohibited health condition and are not receiving hospice services. Resident #3(R3), R1,and R2 are bedridden per physician's report, facility has a fire clearance for 1 bedridden resident and is currently operating outside their license. R1 and R3 have full bed rails in their beds and are not receiving hospice services. Resident #4-#6(R4-R6) and R2 have half bed rails in their beds and no bed rail physician order/request was observed in their files. R5 and R6 do not have a TB test clearance in their file. R6's last physician report is dated 8/15/20 and has a dementia diagnosis. LPA reviewed 5 staff, facility's Infection Control plan and Emergency Disaster Plan (LIC 610E 10/03) last reviewed on 8/30/22. Last fire drill was conducted on 3/29/24. LPA obtained a copy of Infection Control PLan and Liability Insurance. During initial visit on 4/16/24, LPAs Flores and Gutierrez observed two beds and male's clothes and shoes in room #6 upon asking the reason staff #2(S2) and administrator stated, S2 sleeps in resident's room #6 per family's request. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Hongwei He staff and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA)s Mary Flores and Christian Gutierrez conducted an unannounced annual visit at the facility using the inspection CARE tool. LPAs met with Winnie Tan and explained the reason for the visit. Administrator arrived 30 minutes later. The facility is licensed to serve 1 bedridden and 5 non-ambulatory residents age 60 and above, with a hospice waiver for 1. The facility located in a commercial/residential area and consist of three (3) cottage units, each unit consist of a living room, kitchen, a bathroom, and two (2) resident rooms, a front yard, two (2) garage, laundry is located in the garage, and a shed. LPAs toured the facility with Winnie Tan, and Checksim Lim and observed the following: Facility is good repair indoor and outdoor. Food supplies were observed in each unit and no grains, no pastas, no rice, no breads, no fruits were observed, few vegetables and meats were observed. No sufficient food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Kitchen in unit #2 (942) floor was observed dirty and cleaning supplies were observed accessible to the residents in a kitchen cabinet, under sink cabinet, and mirror storage. Unit #1(940) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap buildup and no skid mat was observed. Water temperature was tested at 109.4 degrees F. Unit #2(942) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap mildew buildup and no skid mat was observed. Water temperature was tested at 120.9 degrees F. Unit #3(944) was observed with sufficient lighting, furniture, and bedding supplies. Bathroom does not have a skid mat in the shower. Bathroom's shower was observed with soap/mildew buildup and no skid mat was observed. Water temperature was tested at 138.2 degrees F. Medication was observed in the refrigerator accessible to the residents. (CONTINUED ON LIC 809C) LPAs reviewed medication for 5 residents. LPAs reviewed staff roster and staff #1(S1) was observed working on unit #1 and does not have a background clearance, per administrator 4/16/24 was S1's first day working at the facility. During this visit LPAs concluded three CARE tool domains: Physical plant, Food Services, and Incidental Medical. LPA Flores will return at a different time to continue annual visit. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Hongwei He staff and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 16, 2024