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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:37:00 PM

Document Has Been Signed on 06/23/2021 03:37 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Laura Hutson TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility regarding complaint (18-AS-20210614162726) allegations that were address during time of visit on 06/23/2021. While at the facility LPA Prieto made the following observations. LPA Prieto observed resident #2 (R2) in resident room. R2 was observed to be in a hospital bed. R2 states that R2 is bedridden and that bed had to be assembled in the room as bed cannot rolled into client room. Interview with administrator Na "Sandy" Zhao, states that R2 is bedridden and arrived to the facility with that diagnosis, Review of facility license states that facility approved to 6 non-ambulatory with no mention of bedridden approval. LPA Prieto also observed administrator certificate for Na Zhao posted in facility hallway with an expiration date of 03/26/2021. LPA Prieto contacted administrator Zhao, who stated that she had yet to complete the courses necessary to bring her administrator certificate current, but in the process of registering for the course.

Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the deficiencies of having an expired administrator certificate and not being fire department cleared for retaining a bedridden client found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).
SUPERVISORS NAME: Joel Esquivel
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2021 03:37 PM - It Cannot Be Edited


Created By: Javier Prieto On 06/23/2021 at 03:11 PM
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
, 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
06/28/2021
Section Cited
CCR
87202(a)(2)

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87202 (a)(2) FIRE CLEARANCE
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department. Bedridden person.
This regulation was not met as evidenced by:
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Licensee to removed client to a facility cleared for bedridden clients and notice client responsible party of transfer.
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LPA observed and interviewed resident #2 who is a hospital bed and states R2 is bedridden. Interview with administrator states R2 arrived to facility with a bedridden diagnosis. License does not state that facility is cleared for bedridden clients. This poses an immediate health and safety risk to client in care.
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Type B
06/28/2021
Section Cited
CCR87405(a)

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 87405 (a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This regulation was not met as evidenced by:
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Licensee to hire or assign an administrator with a current administrator certificate. Administrator Zhao to submit administrator certificate when current and valid to licensing office
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LPA observed an administrator certificate for Ms Zhao with an expiration date of 03/26/2021. Ms Zhao states that she does not have a current administrator certificate. This poses a risk to clients 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:Joel Esquivel
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


LIC809 (FAS) - (06/04)
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