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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 07/01/2024
Date Signed: 07/01/2024 01:59:03 PM

Document Has Been Signed on 07/01/2024 01:59 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/
DIRECTOR:		BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:4091 ELDERBERRY RIDGETELEPHONE:
(909) 994-6199
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 2DATE:
07/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Sahian Suarez CamachoTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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On 07/01/2024 at 08:50 AM, Licensing Program Analyst (LPA) Melody Brown met with staff Sahian Suarez Camacho to initiate Case Management Visit. Administrator Brandon Marquez was contacted and informed of the visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the tour of the facility, LPA Brown observed five (5) knives in the kitchen drawer, not locked and accessible to residents in care. Deficiency will be issued. Also, LPA Brown observed Resident #3 (R3) with full bed rail and per documents review, R3 was not on hospice and no written documentation from R3's physician indicating the need for full bed rail and no full bed rail exemption was submitted to Community Care Licensing Division (CCLD). Deficiency will be issued.

Moreover, LPA Brown, observed that there's no Administrator present at the facility during working hours and LPA Brown requested S2 to contact Administrator Marquez and Administrator Marquez reported to LPA Brown unable to to go to the facility during the visit for personal reasons. Also, S2 reported that Administrator Marquez was not checking or visiting the facility. S2 added that Administrator Marquez was always at their Fontana facility. Deficiency will be issued. Also, LPA Brown observed no Administrator present at the facility during working hours. Deficiency will be issued.



In addition, per documents review, LPA Brown observed R3 admitted to the facility on 03/29/2023 but with no completed and updated Medical Assessment or Physician Report (LIC602) as form LIC602 on R3's file does not have Physician Signature and signature date. Deficiency will be issued.

Per records review, the facility was cited for the same regulations within 12-month period for HSC 1569.618(a) and CCR 87468(a), civil penalty will be issued today, 07/01/2024 with the amount of $250.00 per repeat violation within 12-month period.

An exit interview was conducted where this report, LIC809, LIC809D, 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
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 07/01/2024 01:59 PM - It Cannot Be Edited


Created By: Melody Brown On 07/01/2024 at 12:17 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: 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)

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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. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87309(a) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
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Based on observation and interview, the Licensee did not comply with the section cited above by not storing the five (5) knives observed in the kitchen cabinet where it's inaccessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.
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Type B
07/12/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date.
Licensee will remove R3 full bed rail and submit proof to LPA Brown at POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #3 (R3) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2024 01:59 PM - It Cannot Be Edited


Created By: Melody Brown On 07/01/2024 at 12:29 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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
HSC
1569.618(a)

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HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (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:
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Licensee stated to submit Signed Statement of Understanding on HSC 1569.618(a) and submit to LPA Brown at POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2024 01:59 PM - It Cannot Be Edited


Created By: Melody Brown On 07/01/2024 at 12:36 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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
87458(a)

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87458 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:

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Licensee stated to schedule R3's Medical Assessment and submit proof to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) has a completed Medical Assessment by R3's Physician prior to acceptance as a resident at the facility as evidenced of R3's Physician Report on file is not complete due to missing Physician signature which pose immediate health, safety and personal rights risk 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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