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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:54:38 PM

Document Has Been Signed on 11/16/2022 01:54 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
SAN BERNARDINO, 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: 3DATE:
11/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Brandon Marquez-AdministratorTIME COMPLETED:
02:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to conduct a Health and Safety check of the residents in care at the facility. LPA Gardner met with Administrator Brandon Marquez and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside and outside, including food supply, medications, physical plant, and the residents in care.

During the tour, LPA found that there was no running water in the facility. The licensee made a payment to Elsinore Valley Municipal Water District while LPA was at the facility to turn the water service back on. The facility was issued a deficiency for no running water during complaint 56-AS-20221115154227.

LPA also found that there were two (2) staff (S1 & S2) working at the facility without a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care. S1 has been working at the facility for one (1) day and S2 has been working at the facility for fifteen (15) days. The facility will be issued two (2) type A deficiencies and civil penalties totaling $600 dollars for allowing the staff to work at the facility without a criminal record clearance.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report(LIC809), LIC809D, LIC421BG, LIC811, and the appeal rights were discussed and provided to Administrator Brandon Marquez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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 11/16/2022 01:54 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/16/2022 at 01:13 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: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87355(e)(1)

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87355. Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background clearance. POC is due 11/17/2022.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for one (1) day without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/17/2022
Section Cited
CCR87355(e)(1)

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87355. Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to remove S2 from the facility and not allow S2 to work at the facility until S2 has a criminal background clearance. POC is due 11/17/2022.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S2 to work at the facility for fifteen (15) days without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons 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:Efren Malagon
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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