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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 06/23/2021
Date Signed: 12/22/2022 09:42:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2021 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210614162726
FACILITY NAME:KUN BAI CARE #2 HOMEFACILITY NUMBER:
331880822
ADMINISTRATOR:ZHAO, NAFACILITY TYPE:
740
ADDRESS:4091 ELDERBERRY RIDGETELEPHONE:
(909) 994-6199
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: 1DATE:
06/23/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Laura HutsonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Neglect/lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to conduct a complaint investigation regarding allegations of neglect/lack of supervision. LPA met with staff Laura Hutson. Reporting party (RP) reported a visit to the facility on 06/12/21 and door was answered by resident #1 (R1). RP entered the facility and did not observe any staff at the facility for approximately 30 minutes until a staff returned to the facility. Interview with administrator Na "Sandy" Zhao acknowledged that staff attempted to communicate with Zhao about leaving the facility but was not able to coordinate a replacement before staff leaving and leaving residents unattended. R1 is no longer residing at the facility. Resident #2 (R2) states that R2 was alone at the facility with R1 on 06/12/21 until staff returned some time later.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20210614162726
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KUN BAI CARE #2 HOME
FACILITY NUMBER: 331880822
VISIT DATE: 06/23/2021
NARRATIVE
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Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation of neglect/lack of supervision is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210614162726
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KUN BAI CARE #2 HOME
FACILITY NUMBER: 331880822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2021
Section Cited
CCR
87411(a)
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87411 (a) - PERSONNEL REQUIREMENTS GENERAL
Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet residents needs.
This requirement was not met as evidenced by:
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Licensee to immediately provide in service training to staff and care of clients and provide LPA with staff roster for all staff scheduled and back up staff of necessary
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Based on interviews, residents #1 and #2 were left at the facility unattended by staff on 06/12/21 for approximately 30 minutes until staff returned to the facility, which poses an immediate health and safety risk to the persons in care
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CCR
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3