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Inspection visit

Routine inspection (multi-day)

ACE SENIOR CARE MANOR, INC.License 1976076817 citations on this visit
7 citations recorded

Inspector’s narrative

What the inspector wrote

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.

Citations

7 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87204(a)Type A

    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.

  • 87307(a)Type A

    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.

  • 87608(a)(3)Type A

    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.

  • 87615(a)(2)Type A

    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.

  • 87705(c)(5)Type B

    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.

  • 1569.695(d)Type B

    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.

  • 87458(b)(1)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the April 18, 2024 inspection of ACE SENIOR CARE MANOR, INC.?

This was a other inspection of ACE SENIOR CARE MANOR, INC. on April 18, 2024. 7 citations were issued: 4 Type A (serious) and 3 Type B.

Were any citations issued to ACE SENIOR CARE MANOR, INC. on April 18, 2024?

Yes, 7 citations were issued (4 Type A, 3 Type B). The first citation was for: "Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.