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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 06/20/2023
Date Signed: 06/20/2023 06:33:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221123151606
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: 5DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Osvaldo Nunes, CaregiverTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff did not bathe residents while in care.
Staff did not ensure facility was clean.
Staff did not ensure resident's laundry needs were met.
Staff did not issue authorized representative a refund.
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. During the course of this investigation LPAs toured the facility, conducted interviews, and reviewed resident records. Resident record review included the admission agreement, physician's report, pre-admission appraisal, and resident information page for R1.It is alleged that the water has been turned off approximately 6 times in recent weeks/months, the last time was for 8 days which affected residents not receiving bathing, that the facility was unclean, and that laundry needs were not met. It was established during a licensing visit conducted on 11/16/2022 that the water was turned off on 11/8/2022 due to non-payment of the water bill.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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-20221123151606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331880822
VISIT DATE: 06/20/2023
NARRATIVE
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 Interview with the administrator revealed that the facility was relying on the neighbors for water to wash dishes and flush toilets. LPA review of the admission agreement contracts on file verified that during the time that the water was turned off, residents could not have been receiving baths as described in the agreements, that the facility staff could ensure the facility was clean, and that laundry needs could have been met. Resident record review included the admission agreement, physician's report, pre-admission appraisal, and resident information page for R1. Investigation revealed the following: On November 18, 2022 R1 passed away. It is alleged that the responsible party did not received a refund for November 2022 prorated rent. LPA review of R1's admission agreement on file, signed by R1's responsible party, indicates on page 12 that refunds will be issued within 60 days after personal property is removed from the location. R1's responsible party removed R1's belongings on 11/25/2022 according to an interview with the Licensee Na "Sandy" Zhao a refund was issued by Administrator Brandon Marquez. LPA interview with the administrator revealed that the refunds are handled by Sandy and they had not issued a refund to R1's responsible party. No documentation has been provided as evidence that a refund was provided. Interview reveals that there are no records of a refund.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20221123151606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331880822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2023
Section Cited
CCR
87464(c)
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The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident. The facility did not meet this requirement while the water was turned off as evidenced by residents not having access to water for bathing. This poses a risk to the health and safety of residents in care.
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Water service has been restored. Licensee agrees to maintain water service at all times.
Type A
06/20/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times...The facility did not meet this requirement while the water was turned off. The facility lacked access to water to adequately clean the facility. This poses a risk to the health and safety of residents in care.
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Water service has been restored. Licensee agrees to maintain water service at all times.
Type A
06/20/2023
Section Cited
CCR
87307(a)(3)(F)
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Basic laundry service (washing, drying, and ironing of personal clothing).The facility did not meet this requirement while the water was turned off. The facility lacked access to water to adequately clean clothing and bedding. This poses a risk to the health and safety of residents in care.
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Water service has been restored. Licensee agrees to maintain water service at all times.
Type B
06/20/2023
Section Cited
CCR
87507(G)(3)(5)(A)
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A refund of any fees paid in advance ... shall be issued ..The facility has failed to issue a refund to R1 as per their admission agreement.
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Licensee will issue a refund to R1's responsible party for the days due. Proof of refund to LPA by POC due date. Failure to issue a refund will result in civil penalties.
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: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
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