331880822-10-6-2021-18-AS-EMAN-CCZW52-20220330165826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:20:27 PM

Unsubstantiated

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
09/28/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210928150807

FACILITY NAME:	KUN BAI CARE #2 HOME		FACILITY NUMBER:	331880822
ADMINISTRATOR:	ZHAO, NA		FACILITY TYPE:	740
ADDRESS:	4091 ELDERBERRY RIDGE		TELEPHONE:	(909) 994-6199
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 2	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Victor Vidrio		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not treat resident with dignity
Staff did not seek medical attention for the resident
Staff left resident unattended
Staff neglect caused dehydration of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA Williams identified herself and met with Caregiver, Victor Vidrio, LPA Williams spoke with Administrator, Na Zhao, over the phone to discuss the purpose of the visit. The investigation consisted of records review, direct observation, and interviews with staff, residents, and witnesses.

In regards to allegation #1, LPA Williams interviewed Staff #1 (S1) who stated that Resident #1 (R1) is always dressed in their own clothing. LPA Williams interviewed Resident #2 (R2) and Resident #3 (R3) who stated that they are always dressed in their own clothing. R2 also stated that they shared a closet with R1 and believes that R1 was always dressed in clothes that R2 observed in their side of the closet. LPA Williams was unable to retrieve statement from R1 due to health condition.

In regards to allegation #2, LPA Williams interviewed S1 who stated that they were in communication with

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210928150807

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: 10/06/2021

NARRATIVE

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R1's family in regards to R1's medical treatment/medications; however, R1's insurance policy was not effective until 9/1/2021. S1 denied observing indication that R1 required emergency medical treatment. LPA Williams interviewed R2 and R3 who both stated that the facility staff are providing timely medical attention. Both R2 and R3 stated that they are being observed for any changes in condition and are seeing their medical health providers as necessary. R2 and R3 denied observing any indication that R1 was in pain or needed any emergency medical treatment.

In regards to allegation #3, LPA Williams interviewed S1 who denied that the residents were left unattended on 9/1/21. S1 stated that Staff #2 (S2) was changing R3's diaper at the time R1 returned from a doctor's appointment. LPA Williams interviewed R3 who stated that S2 was changing R3's diaper at the time R1 returned to the facility on 9/1/2021. R3 stated that the doorbell rang as S2 was finishing up changing R3. R3 stated it took "about two or three minutes" before S2 answered the door. LPA Williams interviewed R2 and R3 who denied that the residents are being left unattended.

In regards to allegation #4, LPA Williams interviewed S1 who stated that they provided and encouraged R1 to drink water; however, R1 refused to. LPA Williams interviewed R2 and R3 who stated that the facility staff do provide residents with water/fluids often. R2 stated that they have observed facility staff provide water to R1; however, R1 refused to drink water on many occasions. LPA Williams observed that both R2 and R3 had water in front of them while being interviewed.

Based on evidence obtained during today’s visit, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to Vidrio at the conclusion of the investigation.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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