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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:50:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/23/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221223153309
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:
12/29/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Caregiver- Sonia GuevaraTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was restrained by staff.
Staff are unable to adequately communicate with residents due to language barrier.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegations. LPA met with Caregiver Sonia Guevara and explained the reason for the visit.

During today’s visit, LPA toured the facility and conducted interviews with residents and staff.

For allegation, Resident was restrained by staff:

LPA was shown a red strap that was attached to bottom of the red couch in the living room, as well as a white strap that was on the kitchen counter. LPA inquired what the straps were used for, LPA was informed by Staff S1 and Resident R2 that the straps were tied on Resident R1 due to constant moving around in a wheelchair. LPA was informed by S1 and R2 that the straps were tied around R1’s legs, around R1’s waist, and around
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20221223153309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331880822
VISIT DATE: 12/29/2022
NARRATIVE
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the wheels of R1’s wheelchair to prevent R1 from being able to move around in the wheelchair. S1 admitted to LPA that they tied the straps on R1 after being given instructions to do so from Staff S2. LPA requested S1 to demonstrate how they tied the wheelchair to the couch, S1 then demonstrated how they tied the wheelchair to the couch. LPA took pictures of the red and white straps and took pictures of the wheelchair demonstration. Based on the evidence gathered, LPA found that the staff restrained the resident to the couch.

For allegation, Staff are unable to adequately communicate with residents due to language barrier:

Upon entry into the facility, LPA asked S1 how many staff were working in the facility. S1 proceeded to bring LPA a document that had R2’s name on it. S1 did not understand LPA’s question and LPA was asked if they spoke Spanish. As LPA was speaking to S1, LPA observed S1 open their cellphone and S1 started typing in a translator application to answer LPA’s questions. During interviews conducted today, LPA found that the residents in care are having a hard time communicating with the staff due to language barriers. Based on the evidence gathered, LPA found that the staff at the facility are not able to adequately communicate to ensure the safety of the residents in care.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met.

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 (LIC9099) was discussed and provided to Caregiver Sonia Guevara, along with a copy of LIC9099D, and a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20221223153309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331880822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87608(a)(5)
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87608. Postural Supports. (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
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The licensee has agreed to read regulation 87608 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to train all staff on the postural support regulations and send LPA an employee signed and dated documentation that shows that all staff has been trained. The POC is due by 12/30/2022.
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Based on interview and observation, the licensee did not comply with the section cited above evidenced by tying a resident’s legs, a residents waist, and a residents wheelchair to a couch using straps to restrict movement in a wheelchair which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/30/2022
Section Cited
CCR
87411(a)
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87411. Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs..
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The licensee has agreed to read regulation 87411 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to provide LPA with a written plan on how they will ensure compliance related to scheduling staff capable of effectively communicating with residents in care, emergency personnel, licensing
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Based on interview and observation, the licensee did not comply with the section cited above evidenced by staff not being able to adequately communicate with residents due to language barrier which poses an immediate health, safety or personal rights risk to persons in care.
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personnel, and others. The POC is due by 12/30/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3