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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 07/02/2021
Date Signed: 07/02/2021 01:17:01 PM

Document Has Been Signed on 07/02/2021 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARDINAL YU-PIN MANORFACILITY NUMBER:
197607034
ADMINISTRATOR:KUN HUFACILITY TYPE:
740
ADDRESS:15602 BELSHIRE AVENUETELEPHONE:
(562) 926-1289
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 49CENSUS: 19DATE:
07/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jerry Lo TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPA's) Nicol Wesley and Luis Mora conducted an unannounced case management visit at the facility and met with Office Manager Jerry Lo to discuss the purpose for todays visit. Administrator Wendy Hu was also present during todays visit.

During the Annual continuation visit that was conducted on 06/15/2021, LPAs requested for the facility to arrange for residents to be assessed and provide updated medical assessments for all residents(specifically Residents #1-#4), prior to close of business on 06/18/2021. The Physician's reports were observed to outdated for several years. The facility is approved to retain one bedridden resident in room #11 in which the ambulatory status has to be determined by a licensed physician. During todays visit, LPAs were informed by Office Manager Jerry Lo that the assessments have not been completed/scheduled. There were no health and safety concerns observed during todays visit.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8) on the attached LIC 809D. Appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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 07/02/2021 01:17 PM - It Cannot Be Edited


Created By: Nicol Wesley On 07/02/2021 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARDINAL YU-PIN MANOR
FACILITY NUMBER: 197607034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited
CCR
87202(a)(2)

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Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire
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The Licensee/Administrator will immediately relocate one of the bedridden residents to the designated bedridden room(room 11) today.

Licensee/Administrator is contact the fire department Fire Marshal provide information, submit LIC 200 and facility sketch(identify the location for bedridden residents) to the
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department... This evidence has not been met as required by: The facility license was approved to retained 1 bedridden resident and currently LPAs observed there to be 2 bedridden residents(room 15 and room 10) This poses a health and safety risk. **Immediate civil penalty will be assessed**.
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licensing department immediately and/or by the next business day.

Office manager Jerry Lo advised that he contacted the fire department and received instructions on how to proceed.
Type B
07/19/2021
Section Cited
CCR87458(a)

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Medical Assessment
Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment
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The Administrator will ensure that all residents in the facility will have current medical assessments on file by POC due date 07/19/2021.
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This requirement has not been met as evidenced by:
LPAs did not observe current Physician's reports for R5-R19 in the resident files. The some reports were outdated for as many as 12 years. This poses a potential risk to the health and safety of residents in care.
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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:Rebecca Orendain
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021


LIC809 (FAS) - (06/04)
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