ACE SENIOR CARE MANOR, INC.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in 1 out of 6 residents bedroom, room #6 is being used by a resident and a staff which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Administrator will ensure each resident room is used as licensed by individual use,will certify in writing that understands 87307, will submit to the departmnet, and will provide a chair for staff in room #6 to use while providing care by POC due date 4/19/24.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 6 residents, R1 - R3 have a prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Administrator will certify in writing that understands facilty may not retain or accept residents with prohibited health conditions per Title 22, submit to the department, and will assist with relocation of R1-R3 to higher level of care by POC due date 4/19/24.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents are bedridden per physician's report which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Administrator will certify in writing that understands facilty may not go beyond the capacity of license while providing care, submit to the department, and will assist with reasses or relocate R1, R2, and R4 to higher level of care by POC due date 4/19/24.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 6 residents have bed rails in their beds and do not have a physcian's order/request on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Administrator will obtain a physician's order/request for each resident using a bed rail R1-R6 , will maintain in file for review, and will submit to the department by POC due date 4/19/24.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(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 Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents, R5-R6 do not have a TB clearance in file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Administrator will obtain TB clearance for R5-R6 and submit a copy to the department by 4/25/24.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Emergency Disaster Plan was last reviewed on 8/30/22, plan does not meet the standards of current version LIC 610E(3/19) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Administrator will update Emergency Disaster Plan to meet the current guidelines and will submit a copy to the department by POC due date 4/25/24.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents, R6 last physician's report is dated 8/15/20 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Administrator will obtain a current physician's report for R6 and will submit a copy to the department by POC due date 4/25/24.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in water temperature in unit #2 tested at 120.9 degrees F., and in unit #3 water temperature tested at 138.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Administrator will adjust water temperature and certify in writing that will ensure water temperature is within 105-120 degrees F by POC due date 4/17/24. Administrator will maintain a daily log of water temperature for unit #2 and #3 and will submit log within 7 days.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 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 and can accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Administrator will ensure all items are inaccessible to the residents and will provide training to staff on section 87309. Administrator will provide a copy of training to the department by POC due date 4/17/24.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 3 staff, staff #1 did not have a background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Administrator will certify in writing that will ensure staff are fingerprint and associate to the facility before working to the department by POC due date 4/17/24. S1 left and will not return to work until cleared and associate.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in after review of each kitchen and garage LPAs did not observed a variety of food supplies suffiicent for 6 residents for at least 2 days of perishables and 7 days on non-perishables which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Administrator will purchase food supplies and submit a copy of receipts and pictures to the department by POC due date 4/17/24.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in medication for resident #1 (R1) was observed in the refrigerator accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Administrator will purchase a lock box to place in the refrigerator for medication storage and will submit picture to the department and will provide training to staff regarding proper storage by POC due date 4/17/24.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in bathroom's showers in each unit were observed with soap, and/or mildew buildup, and kitchen floor in unit #2 was not clean which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2024 Plan of Correction Administrator will clean and remove buildup from each shower and kitchen #2 and will submit a picture to the department by POC due date 4/23/24.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 3 out of 3 showers did not have a skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2024 Plan of Correction Administrator will purchase and place skid mats in each bathroom and will submit a picture to the department by POC due date 4/23/24.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Unit 942 and 944 medication cabinet in hallways were observed unlocked, pad locks latched on cabinet door but not securely shut closed.LPA found Staff #4 medication bottle containing pills on table stand under living room TV. Based on LPA observation the licensee did not comply with the section cited above resulting in 5 out of 5 residents, which poses an immediate helath, safety or personal rifhts risk to residents in care.

Official plan of correction

Facility Administrator immedeatly removed staff medication out of facility premisis and locked all cabinets, instructing staff were to find keys and what the code is for padlocks were. Facility Administartor will provide all staff locker for each unit for personal belongings by date 7/31/23 . Facility Administrator will provide an in-service training on Regulation 87465 Incidental Medical and Dental Care and provide proof to LPA by date 7/31/23.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in 5 out of 5 residents. LPA observed at Unit 942 and 944 Unit, having knife cabinets in kitchen padlocks observed unlocked, pad locks latched but not securely shut closed. Observations poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility Administartor will ensure all disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Licensee must re-train staff on regulation 87309 Storage Space and how to safe guard these items and send proof of training by 7/31/23. Admin. shut padlocks and provided staff with insturctions on where to locate padlock key and provide passcode to staff in unit 944.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2023 Plan of Correction Licensee will lower water heater by 04/05/23. Licensee will create a water log and record water temperature, every 24hrs for the next 7 calendar days. Proof must be submitted to LPA by 4-11-23 via email.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2023 Plan of Correction Licensee will place a sign above kitchen sinks with warning signs " WATER TEMPERATURE MAY DELIVER ABOVE 125 DEGREES F. "

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2023 Plan of Correction Licensee will ensure all disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Licensee must re-train staff on how to safe guard these items and send proof of training and receipt of staff receiving training. Staff removed items while LPA was present and placed in location inaccessible to residents.

Official classification

Type A

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2023 Plan of Correction Licensee will ensure LIC 308 is on file in lieu of absence. LPA must recieve no later than 04/05/23 via email.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2023 Plan of Correction Licensee will retrain staff on safe guarding of medications and only allow direct access others persons other than employees resonpsible for the supervision of the centrally stored medication.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2023 Plan of Correction Licensee will retrain staff on how to properly record medication dosage and submitt proof to LPA.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2023 Plan of Correction Staff will remove all clutter from dining areas and living room area. Photo proof must be submitted to LPA.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2023 Plan of Correction Licensee will clean kitchen floors and bathrooms floors. Photo proof must be submitted to LPA

Official classification

Type B

Official code

87308(c)

Regulation authority

CCR

What the official deficiency says

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2023 Plan of Correction Licensee will remove all extra hygiene products in common areas and move to proper storage area. Photo proof required.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2023 Plan of Correction Licensee will store such items away from food supplies. Photo proof of correction required.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents..... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met evidenced by: Based on observation, on 6/30/22 the facility had one expired food item in refrigerator. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated it was caregiver item and disposed of expired food item during visit. Licensee shall conduct a regular inventory of all food goods and discard all expired foods. Submit a written plan stating what was done, and proof of staff training by POC due date.

Deadline recorded: Jul 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

b (b) The following food service requirements shall apply: All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement was not met evidenced by: LPA observed both refirgrators and the freezer are in unsanitary condition.

Official plan of correction

Licensee cleaned both refrigerators during visit. ***no further action is required***

Deadline recorded: Jul 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(3)

Regulation authority

CCR

What the official deficiency says

(a)(3) There shall be arrangements for separation and care of residents whose illness requires separation from others. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above for Resident #3 whose medications Ergocalciferol 1250 mcg and Carvedilol 6.25 mg were out of pills which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/11/2022 Plan of Correction The Administrator shall ensure that resident #3 medications are refilled in advance when medications run low. Administrator shall submit proof that the medication is refilled and given by 5/11/22.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

8755 General Food Services Requirements: b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for not maintaining a minimum of one week of nonperishable foods at the facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/17/2022 Plan of Correction The Administrator shall purchase at least of nonperishable items to store at the facility. The POC shall be sent to LPA by 5/17/22.