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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:04:39 AM

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
11/15/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221115154227
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: 4DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Osvaldo Nunes-Aldrate "Aldrete"- CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Licensee does not have sufficient resources to meet operating costs for care of residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to deliver findings for the above complaint allegation that was initiated on 11/16/2022. LPA met with Caregiver Osvaldo Nunes-Aldrate "Aldrete" and explained the reason for the visit.

For allegation, Licensee does not have sufficient resources to meet operating costs for care of resident:

State licensing’s audit team reached out to the licensee to provide financial documents to complete a financial audit of the facility. During review of the documents provided, it was found that the licensee did not provide all the requested documents needed to complete the audit. The documents that were provided were incomplete and not for the audit period that was requested. By failing to provide the documents required, the licensee has not proved to state licensing that there is a financial plan in place to meet the facilities operating costs to provide care for the residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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-20221115154227
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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
87213
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The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements.
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The licensee has agreed to read regulation 87213 entirely and send LPA a self certified letter that the regulation was read and understood. The POC is due 5/10/23.
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Based on interview and record review, the licensee did not comply with the section cited above by not providing all the requested documents to complete a financial audit and did not prove that there is a financial plan in place 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20221115154227
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: 05/09/2023
NARRATIVE
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Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence the standard has been met.

During today’s visit, one (1) deficiency was 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 Osvaldo Nunes-Aldrate "Aldrete", 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: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3