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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:15:54 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/22/2023 11:15 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
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:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Caregiver Dennis GuttierezTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Chitgian and Licensing Program Manager (LPM) Efren Malagon made an unannounced visit to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver(C1) Dennis Gutierrez and explained the purpose of the visit. At the time of visit there was one (1) staff and two (2) residents present.

LPA reviewed documents and observed that C1 did have fingerprint clearance, however is not associated to the facility. LPA provided the LIC 9182 to C1 for submission.

At 9:30 am, LPA toured the facility and made observations regarding the infection control measures that have been implemented. During the inspection of the kitchen, LPA observed the knives and cleaning chemicals in the kitchen were in an unlocked cabinet. This poses an immediate health and safety risk to residents in care. Deficiency issued. LPA explained the importance of locking away the knives, chemicals and detergents to C1, to which C1 proceeded to lock away. LPA also explained the facility is to be kept clean and sanitary at all times. The smoke detector was observed hanging by electrical wires from the ceiling, which poses a potential health and safety risk to residents in care. Deficiency issued.

At 9:35am, LPA observed the laundry room door does not have a lock. The door was observed to be open. When inspected, the laundry room had bleach, detergents, and disinfectant spray bottles accessible to residents in care. This poses an immediate health and safety risk to residents in care. Deficiency issued.

LPA continued the walk-through and observed the door chimes at the entrance, back door, and garage exit did not have an auditory sound. This poses a potential risk to residents with dementia in care. Deficiency issued. The facility also has an outstanding balance for Licensing Fees in the amount of $2,226.00.

Based on the observations made during todays visit, four(4) deficiencies were issued. A copy of this report, LIC 809-D, and appeal rights were provided to caregiver Dennis Gutierrez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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 02/22/2023 11:15 AM - It Cannot Be Edited


Created By: Victoria Chitgian On 02/22/2023 at 10:29 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
87705(f)(1)

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(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives… and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
The licensee failed to lock away the knives which poses an immediate risk.
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Licensee agrees keep the knives locked away to read the regulation in its entiredy and submit a letter stating understanding the regulation to LPA no later than 2/23/2023.
Type A
02/23/2023
Section Cited
CCR
87705(f)(2)

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(f) The following shall be inaccessible to residents with dementia: (2) … toxic substances such as … cleaning supplies and disinfectants. This requirement is not met as evidenced by: The licensee failed to lock away the chemicals and detergents which poses an immediate risk.
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Licensee agrees to lock all the detergents and chemicals away inaccessible to residents. Licensee agrees read the regulation in its entiredy and submit a letter stating understanding the regulation to LPA no later than 2/23/2023.
Type B
02/24/2023
Section Cited
CCR87303(a)

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Maintenance and Operation
(a)The facility shall be clean... sanitary and in good repair at all times.
This requirement is not met as evidenced by: The Licensee failed to repair the smoke alarm detector hanging in the kitchen ceiling which poses a potential risk to residents in care.
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Licensee agrees to repair the smoke detector in the kitchen no later than 2/24/2023 and submit a picture to LPA.
Type B
02/24/2023
Section Cited
CCR
87705(j)

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Care of residents with dementia:
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: The licensee failed to ensure door chimes to all exits are operating.
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Licensee agrees to repair or replace all door entrance and exit chimes, or install an auditory device in which will sound. Licensee will submit a video to the LPA no later than 2/24/2023.
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:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
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