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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:44:56 AM

Document Has Been Signed on 12/22/2022 09:44 AM - 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
, 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:
12/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Sonia Palafox, StaffTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to amend complaint #18-AS-20210614162726 that was issued on 06/23/2021. Amendment is to omit deficiency of Reporting Requirements (87211 (a)(1)) and issue deficiency on Facility Evaluation Report (LIC 809) as the deficiency on complaint #18-AS-20210614162726 was not an allegation and should be cited on a separate report. LPA Prieto arrived to the facility and met with staff Sonia Palafox and explained the purpose of the visit. Staff Palafix contacted Administrator Brandon Marquez Guitierrez who stated he could not readily arrive to the facility. LPA Prieto explained the purposed of the visit of signing amended reports previously cited to the facility and asked if staff Sonia Palafox would sign the reports and a copy would be left with the facility. Administrator Brandon stated that would be acceptable. This report was signed by LPA Prieto and staff Palafox and a copy of this report, as well as the amended complaint #18-AS-20210614162726, was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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 12/22/2022 09:44 AM - It Cannot Be Edited


Created By: Javier Prieto On 12/15/2022 at 04:55 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
, CA 92507

FACILITY NAME: KUN BAI CARE #2 HOME
FACILITY NUMBER: 331880822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
Section Cited
CCR
87211(a)(1)

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87211 (a) (1) REPORTING REQUIREMENTS
A writen report shall be submitted to the licensing agancy and to the person responsible for the resident within seven days of occurrance...
This requirement was not met as evidnced by:
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POC was issued from previous complaint date of 06/23/21
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Adminstrator Na Zhao confirmed with LPA Prieto that an incident report as not send nor was the Licensing office notified of the incident that occurred on 06/23/21
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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:Karen Clemons
LICENSING EVALUATOR NAME:Javier Prieto
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


LIC809 (FAS) - (06/04)
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