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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:17:37 PM

Document Has Been Signed on 12/06/2021 12:17 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, 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: 2DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Brandon MarquezTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Melody Brown and Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPAs were greeted and granted entrance by caregivers Maria Gitau and Laura Hutson and LPAs explained the purpose of today's visit. Administrator Sandy Zhao was contacted and informed of the facility visit but Administrator Zhao reported that she was unable to go to the facility for the inspection. Caregiver Hutson accompanied LPAs Brown and Allen on a tour of the inside and outside of the facility.

During today’s visit, LPAs Brown and Allen made observation pertaining to the facility’s current infection control measures. LPAs Brown and Allen observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor resident regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Throughout today's inspection, LPAs Brown and Allen observed and found out that caregivers S2 and S3 were not fingerprinted or cleared. Administrator Zhao was contacted, and she confirmed that her two (2) caregivers S2 and S3 were not fingerprinted.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/06/2021
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LPAs Brown and Allen will be issuing a citation since the licensee/administrator failed to ensure that S2 and S3 were fingerprinted and associated to the facility prior to employment.

An exit interview was conducted with caregiver Brandon Marquez and a copy of this report (LIC 809), LIC809D, LIC421 BG and Appeal Rights were provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2021 12:17 PM - It Cannot Be Edited


Created By: Melody Brown On 12/06/2021 at 11:28 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
, 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: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, licensee failed to ensure S2 and S3 were fingerprinted and associated to the facility prior to employment. This is an immediate health and safety risks to the resident in care..
POC Due Date: 12/07/2021
Plan of Correction
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Licensee/Administrator will remove S2 and S3 from the facility immediately. Licensee will submit an LIC 9182 along with clear photo ID by mail or in person to CCL by POC date 12/07/2021.
A civil penalty will be assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021


LIC809 (FAS) - (06/04)
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