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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:57:16 PM

Document Has Been Signed on 12/29/2022 12:57 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: 2DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Caregiver- Sonia GuevaraTIME COMPLETED:
01:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management during a visit for complaint control number 56-AS-20221223153309. LPA met with Caregiver Sonia Guevara and explained the reason for the visit. At the time of the visit, there were two (2) residents, and one (1) staff present.

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

During interviews conducted with Staff, Staff S1 stated that they were not aware of the residents’ medical special diet. LPA observed S1’s medical documents dated 07/21/2022 showing that R1 has a medical special diet. S1 stated they were not shown the medical documents and they were not informed of the resident’s medical need. During interviews with the resident, LPA was informed that the medical special diet is not being followed by the staff.

Based on observations today, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report(LIC809) was discussed and provided to Caregiver Sonia Guevara, along with a copy of LIC809D, LIC 811, and 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
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 12/29/2022 12:57 PM - It Cannot Be Edited


Created By: Ryan Gardner On 12/29/2022 at 12:21 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: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87555(b)(7)

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87555. General Food Service Requirements. (b)The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
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The licensee has agreed to read regulation 87555 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 the residents medical special diet will be followed by all the staff in the facility. The POC is due by 12/30/2022.
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Based on interview and document review, the licensee did not comply with the section cited above evidenced by not following the resident’s medical special diet 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: 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


LIC809 (FAS) - (06/04)
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