<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:55:17 PM

Document Has Been Signed on 10/10/2023 03:55 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:BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:4091 ELDERBERRY RIDGETELEPHONE:
(909) 994-6199
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 3DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brandon Marquez-Gutierrez- AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Volunteer/Non-Client Resident Jair Melgarejo Martinez was granted entry to the facility. Administrator Brandon Marquez-Gutierrez arrived at the facility after LPA made a phone call to the licensee. At the time of the visit there was one (1) staff present, one (1) Volunteer/Non-Client Resident present, and three (3) residents present.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and the current census is three (3) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The resident’s (R1, R2, & R3) bedrooms did not have sheets and mattress covers on their beds. The shower in R2 and R3’s bedroom did not have a non-slip mat on the shower floor. Deficiencies will be issued for the sheets, mattress covers, and non-slip mat. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 109.7 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having the required staff present in the facility which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.618 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the health and safety code and or have the administrator present in the facility. The POC is due by 10/11/2023.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having a staff present in the facility with CPR training which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.618 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the health and safety code and or have the current staff trained in CPR. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having staff with the required training/training documents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.625 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the health and safety code and or have the current staff trained. The POC is due by 10/11/2023.

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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having staff with the required training/training documents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.625 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the health and safety code and or have the current staff trained. The POC is due by 10/11/2023.
Type A
Section Cited
HSC
1569.625(c)(4)
Other Provisions
(c) The training shall include, but not be limited to, all of the following: (4) Policies and procedures regarding medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having staff with the required training/training documents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.625 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the health and safety code and or have the current staff trained. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having staff with the required training/training documents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read section 87411 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to hire the required staff to follow the regulation and or have the current staff trained. The POC is due by 10/11/2023.
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having the required resident documents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87458 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to contact the resident’s medical providers and have the resident’s physicians complete a medical assessment. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by leaving medication unlocked in the refrigerator and by leaving unlocked medication in a zip lock bag on the desk in the living room area which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to purchase a lock box for medications that need to be stored in the refrigerator and has agreed to not leave medication in Ziploc bags. The POC is due by 10/11/2023.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by storing a resident’s medications in a plastic weekly container box which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to store the resident’s medications in the original prescription containers. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having a non-slip mat in the bathroom shower which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87303 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to put a non-slip mat in the bathroom shower. The POC is due by 10/11/2023.
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having sheets and mattress covers on the resident’s beds which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87307 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to put sheets and mattress covers on the resident’s beds. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having the administrator present in the facility during normal working hours which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read health and safety code 1569.618 entirely and send LPA a self-certified letter that the section was read and understood. The licensee has agreed to have the facility administrator present during normal working hours and or hire additional administrators. The POC is due by 10/17/2023.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having the required documents in the resident’s facility file which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the section was read and understood. The licensee has agreed to complete the required documents and put the documents in the resident’s facility files. The POC is due by 10/17/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having the required documents in the resident’s facility file which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87456 entirely and send LPA a self-certified letter that the section was read and understood. The licensee has agreed to complete the required documents and put the documents in the resident’s facility file. The POC is due by 10/17/2023.
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having a first aid kit which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the section was read and understood. The licensee has agreed to purchase a first aid kit for the facility. The POC is due by 10/11/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 10/10/2023 03:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 10/10/2023 at 01:51 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: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having a first aid manual which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the section was read and understood. The licensee has agreed to purchase a first aid manual for the facility. The POC is due by 10/11/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a cabinet with the majority of the resident’s medications locked in the living room area. LPA found one Ziplock bag with two (2) pills inside of it laying on the desk in the living room area. LPA also found unlocked medication in the refrigerator. The facility is storing R1’s medications in a plastic weekly container instead of the original prescription container from the pharmacy. The facility will be issued deficiencies for medication issues. The facility does not have first aid kit and a first aid manual. The facility will be issued deficiencies for not having the required first aid kit and manual.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: The facility does not have an administrator and or a manager present in the facility enough hours to appropriately manage the facility. The facility does not have facility manager. The facility does not have a designated person who can manage the facility during the absence of the administrator. The administrator is only at the facility every other (5) days due to managing a total of five (5) facilities. The facility will be issued deficiencies for the supervision issues. The licensee is also hiring staff as volunteers and listing them as Non-client residents on the CDSS Guardian system.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. The files were missing physician’s reports, admissions agreements, and preadmissions appraisals. The facility will be issued deficiencies for the resident record issues. LPA reviewed three (3) staff files/volunteer files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that two (2) of the three (3) staff do not have CPR trainings, staff are not properly trained in medication, dementia care, and basic trainings required for an RCFE. The facility will be issued deficiencies for the staff training and record issues. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, sixteen (16) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and appeal rights were discussed and provided to Administrator Brandon Marquez-Gutierrez

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 11 of 11