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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 06/20/2023
Date Signed: 06/20/2023 06:32:23 PM

Document Has Been Signed on 06/20/2023 06:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KUN BAI CARE #2 HOMEFACILITY NUMBER:
331880822
ADMINISTRATOR:BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:4091 ELDERBERRY RIDGETELEPHONE:
(909) 994-6199
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:TIME COMPLETED:
06:45 PM
NARRATIVE
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During the course of an investigation Licensing Program Analyst (LPA) Amy Goldenberg found that Na "Sandy" Zhao provided LPA with false statements regarding a refund. While being interviewed regarding issing a refund to responsible party of Resident number 1 (R1) Sandy tells LPA that the refund was handled by the facility administrator, Brandon Marquez. During LPA visit on 6/2/2023 LPA spoke telephonically with the Administrator regarding the statement that Sandy made that the administrator had issued the refund, to which they reports that Sandy handles all the refunds and he did not provide a refund. Evidence supports that Sandy has provided false statements to LPA Goldenberg on 6/2/2023 regarding the administrator issuing a refund R1's responsible party. LPA has found that a violation has occurred and is issuing a deficiency. See also LIC 809D. This report was reviewed along with appeal rights to the facility representative. LPA provided a copy to the facility representative prior to leaving the facility.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2023 06:32 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 06/20/2023 at 04:32 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
, 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
06/21/2023
Section Cited
HSC
87207

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False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement
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Licensee to provide statement of understanding regarding the regulation cited along with an LIC 9098 self certifying that they will no longer provide any
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regarding the facility or any of the services provided by the facility. The Licensee has failed to meet this requirement as evidence that Licensee provided LPA with a false claim that she issued R1's responsible party a refund
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 agent of this department with misleading statements by POC due date.

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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: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


LIC809 (FAS) - (06/04)
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