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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 07/01/2024
Date Signed: 07/01/2024 01:53:51 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
06/24/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240624141719
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: 2DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sahian Suarez CamachoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure that the cleaning supplies were inaccessible to residents.
Staff did not ensure that medications were properly stored and locked.
INVESTIGATION FINDINGS:
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On 07/01/2024, Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced to initiate and deliver findings for the above allegations. LPA Brown was greeted and granted entry by Staff #2 (S2) and LPA Brown explained the purpose of the visit. Administrator Brandon-Marquez Gutierez was contacted and informed of the vsit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observations and interviews with relevant parties. The allegation indicates that Staff did not ensure that the cleaning supplies were inaccessible to residents. LPA Brown obtained evidence to corroborate the allegation above. During the quick tour of the facility on 07/01/2024, LPA Brown observed multiple bottles of cleaning supplies and chemicals under the kitchen sink, not locked and accessible to residents in care. S2 immediately locked the multiple bottles of chemicals under the sink with a padlock. S2 reported to LPA Brown that they were not aware that chemicals must be locked and inaccessible to residents.
**Continuation in LIC9099C**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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 6
Control Number 56-AS-20240624141719
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: 07/01/2024
NARRATIVE
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The second allegation indicates Staff did not ensure that medications were properly stored and locked. During the quick tour of the facility on 07/01/2024, LPA Brown observed residents medications were kept in a cabinet in the corner of the living room but not locked and accessible to residents in care. S2 immediately locked the residents medication during the facility visit. S2 reported to LPA Brown that they were not aware that resident medications must be locked and not accessible to residents.

Based on LPA Brown’s observations and interview, the preponderance of evidence standard has been met, and therefore the above allegations of Staff did not ensure that the cleaning supplies were inaccessible to residents (Allegation #1), Staff did not ensure that medications were properly stored and locked (Allegation #2) are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

Per records review, the facility was cited for the same regulation within 12-month period for CCR 87465(h)(2) on 10/10/2023, therefore civil penalty will be issued today, 07/01/2024 with the amount of $250.00 for repeat violation within 12-month period.

An exit interview was conducted where this report, LIC9099, LIC9099D, LIC421FC and Appeal Rights were discussed and provided to Sahian Suarez Camacho.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20240624141719
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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
87309(a)(1)
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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown on Plan of Correction (POC) due date.
Licensee locked the multiple bottle of chemicals/cleaning solutions during the visit.
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Based on observation, and interview, the Licensee did not comply with the section cited above by not locking the multiple bottle of cleaning solutions, and chemicals under the kitchen sink making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.
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Type A
07/02/2024
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (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:
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Licensee stated to train all staff on CCR 87465(h)(2) and submit proof of all staff training log to LPA Brown on POC due date.

Licensee locked the medicine cabinet where the resindents medications are stored during the visit.
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Based on observation, and interview, the Licensee did not comply with the section cited above by not ensuring that residents centrally stored medications are kept in a safe and locked place that is not accessible to residents in care which pose immediate health, safety and personal rights risks to residents 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: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/24/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240624141719

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: 2DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sahian Suarez CamachoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff did not ensure that the resident was hydrated.
Staff did not ensure that the facility was kept clean.
INVESTIGATION FINDINGS:
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13
On 07/01/2024, Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced to initiate and deliver findings for the above allegations. LPA Brown was greeted and granted entry by Staff #2 (S2) and LPA Brown explained the purpose of the visit. Administrator Brandon-Marquez Gutierez was contacted and informed of the vsit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observations and interviews with relevant parties. The allegation indicates that Staff did not ensure that the resident was hydrated. During the investigation, LPA Brown did not find evidence to corroborate the allegation.
Interviews with two (2) of two (2) residents indicated that staffs at the facility are always checking on them if they are thirsty and if they want something to drink. Resident interviews revealed there's no incident that staffs at the facility did not provide them anything to drink. Interview with S2 indicated that they are always checking on their residents if they are thirsty and need something to drink ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20240624141719
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: 07/01/2024
NARRATIVE
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and they always provide them drinks with meals. During the visit on 07/01/2024, LPA Brown observed S2 providing water to drink to Resident #2 (R2) and Resident #3 (R3).

The second allegation indicates Staff did not ensure that the facility was kept clean. Interviews with two (2) of two (2) residents indicated that staffs at the facility are cleaning the home twice a day and they both reported that staffs at the facility always maintains the facility clean. Interview with S2 indicated that they are cleaning the facility everyday to keep it clean and S2 reported to LPA Brown that there's no incident that a staff did not ensure that the facility's kept clean. During the facility visit on 07/01/2024, LPA Brown observed the facility was kept clean by S2.

Based on the evidence, the allegations that Staff did not ensure that the resident was hydrated (Allegation #1), Staff did not ensure that the facility was kept clean (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.


An exit interview was conducted where this report, LIC9099 was discussed and provided to Sahian Suarez Camacho.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6