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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:46:53 PM

Document Has Been Signed on 10/28/2024 04:46 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:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Sahian Suarez CamachoTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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On 10/28/2024 at 11:20 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and two (2) residents present. Administrator Brandon Marquez and Licensee Sandy Zhao was contacted and informed of the visit. Administrator Marquez was not at the facility during the visit. LPA Brown explained the purpose of the visit to staff Sahian Suarez Camacho..

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory. The facility has six (6) Hospice Waiver. The current census is two (2) residents. LPA Brown was accompanied by staff Camacho 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 Division (CCLD). The facility is equipped with operating smoke detectors but LPA Brown observed no carbon monoxide at the facility. Deficiency will be issued. LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 107 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as mattresses and storage space, however, LPA Brown observed missing one (1) chair and one (1) lamp in resident #1 (R1) and resident #2 (R2) bedroom. Technical Violation issued. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and the customized bathroom tiles in the resident bathrooms. ***Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/28/2024
NARRATIVE
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Also, LPA Brown observed Resident #2 (R2) with full bed rails and Staff #2 S2) reported to LPA Brown that R2 is not on Hospice Care and no written order from R2 physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R2's full bed rails. Deficiency will be issued.

In addition, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. Furthermore, during the tour of the facility, LPA Brown observed one (1) scissor, four antibiotic ointments in R1 and R2 bedroom, not locked and accessible to residents in care. Also, LPA Brown observed two (2) gallons of bleach, three (3) bottles of cleaning solutions, one bottle of laundry detergent in the garage, not locked and accessible to residents in care and one (1) scissor in the hallway closet, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet.

Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. However, LPA Brown observed the facility's auditory device to alert staff to monitor exits is in disrepair. Deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: LPA Brown observed no administrator present at the facility during normal working hours. Deficiency will be issued. Also, LPA Brown observed one (1) staff working at the facility and per staff interview and records review, no staff's scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued..

***Continuation in LIC809C ***

***This is an amendment copy of the form LIC809C issued today, 10/28/2024***

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

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/28/2024
NARRATIVE
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Record Review: LPA Brown observed Infection Control Plan maintained at the facility. However, LPA Brown observed the liability insurance maintained at the facility is for Worker's Compensation and Employers' Liability and it does not cover injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three (3) million dollars ($3,000,000) in the total annual aggregate caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Deficiency will be issued. Licensee updated the required liability insurance during the visit today, 10/28/2024 and provided LPA Brown a copy. LPA Brown observed no fire and earthquake drill conducted at the facility. Deficiency will be issued. LPA Brown observed that the facility did not review the emergency disaster plan annually as evidenced of the Licensee/Administrator did not sign the emergency disaster plan this year. Deficiency will be issued.

LPA reviewed two (2) resident files for admission agreements, updated physician reports, Pre-placement Appraisals, Centrally Stored Medication List, Preplacement Needs and Services Plan. LPA Brown observed Resident #2 (R2) physician report does not have physician signature and signature date and per documents review, R2 was admitted to the facility on 03/29/2023. Deficiency will be issued. LPA Brown observed Resident #2 (2) Physician Assessment indicated dementia but R2 does not have the required annual medical assessment for residents with dementia. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results and LPA Brown observed Staff #2 (S2) First Aid/CPR certification expired on 10/22/2024. Deficiency will be issued.

During medication audit, LPA Brown observed that facility staff did not assist Resident #1 (R1) with one (1) medication. Deficiency will be issued. Also, LPA Brown observed Resident #2 (R2) with one (1) medication without R2's physician authorization. Deficiency will be issued.



Per records review, the facility was cited for the same regulations within 12-month period for CCR 87309(a), CCR 87458(a) and HSC 1569.618(a). Civil penalty will be issued today, 10/28/2024 with the amount of $250.00 per repeat violation within 12-month period.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421FC, LIC9102TV and LIC9102TA and Appeal Rights were discussed and provided to Sahian Suarez Camacho.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 16 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facilitgy has the required carbon monoxide detectorswhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee stated to obtain/purchase the required carbon monoxide detector and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87309(a)
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:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the observed one (1) scissor four antibiotic ointments in R1 and R2 bedroom, theb two (2) gallons of bleach, three (3) bottles of cleaning solutions, one bottle of laundry detergent in the garage and one (1) scissor in the hallway closet, were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee immediately locked the observed scissors and chemicals during the visit. Licensee stated to train all staff on CCR 87309(a) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) who'son duty and on the premises at all times have the required cardiopulmonary resuscitation (CPR) training and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee stated to submit S2 proof of enrollment/certification on cardiopulmonary resuscitation (CPR) training and first aid training to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review)], the licensee did not comply with the section cited above by not ensuring that facility staffs are assisting Resident #1 (R1) with one (1) of R1's medication as evidenced of R1's medication was not given per R1's physician directions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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2
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4
Licensee stated to provide additional training to all staff on CCR 87465(a)(4) and submit proof to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that one (1) medication of Resident #2 (R2) has R2's physician authorization which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee staeted to train all staff on CCR 87465(a)(5)(A) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by admitting Resident #2 (R2) at the facility on 03/29/2023 and not ensuring that R2 physician report has physician signature and signature date which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee stated to submit R2 medical appointment date to complete the required medical assessment and submit proof to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 5 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(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:
Deficient Practice Statement
1
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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #2 (R2) with full bed rail and R2's not on hospice and no letter/waiver was submitted and approved by CCLD which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee stated to remove R2's full bed rail and submit proof to LPA Brown on Plan of Correction due date. LPA Brown informed Licensee to submit R2 letter/waiver with doctor's written order to CCLD for approval if they prefer R2 to have full bed rail.
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff schedule to work the night shift as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
Licensee stated to schedule a staff to work the night shift as required for facility with dementia residents and submit an updated staff schedule and Personnel Report (LIC500) to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 6 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) have an annual medical assessment as required for dementia resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
Licensee stated to submit R2 medical appointment date to complete the required annual medical assessmet for resident with dementia to LPA Brown on Plan of Correction (POC) due date.
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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 7 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility that cover injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three (3) million dollars ($3,000,000) in the total annual aggregate caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee updated the facility's liability insurance as required and submitted a copy to LPA Brown during the visit. Plan of Correction (POC) cleared.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights were maintained in hallways and passages to non-private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain and install night lights to hallways and passages to nonprivate bathrooms and submit proof to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 8 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

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 observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the Administrator's present at the facility during working hours as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee stated to hire an additional Administrator to ensure that Admistrator's at the facility during working hours as required and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's planned activities at the facility for the socialization of residents and not just watching television at teh living room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a monthly planned activities for residents socialization to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 9 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required fire and earthquake drill at least quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee stated to conduct the required fire and earthquake drill and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the emergency disaster plan was reviewed annually and signed by the Administrator or LIcensee which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee stated to review and sign the Emergency Disaster Plan and submit proof to LPA Brown on POC due date.
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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 10 of 16
Document Has Been Signed on 10/28/2024 04:46 PM - It Cannot Be Edited


Created By: Melody Brown On 10/28/2024 at 02:46 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the auditory device that alert staff to monitor exits are not in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
LIcensee stated to repair the auditory device that alert staff to monitor exits and submit proof to LPA Brown on Plan of Correction (POC) due date.
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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 11 of 16