331880822-11-7-2024-56-AS-MBRN-DASUXA-20241107145800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 11/07/2024
Date Signed: 11/07/2024 02:58:09 PM

Document Has Been Signed on 11/07/2024 02:58 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 HOME		FACILITY NUMBER:	331880822
ADMINISTRATOR/ DIRECTOR:	BRANDON MARQUEZ-GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	4091 ELDERBERRY RIDGE		TELEPHONE:	(909) 994-6199
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY: 6		CENSUS: 2	DATE:	11/07/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Sahian Suarez Camacho		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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On 11/07/2024 at 12:20 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee Sandy Zhao and Administrator Brandon Marquez and reports provided to staff Sahian Suarez Camacho from visit on 10/28/2024. LPA Brown met with staff Sahian Suarez Camacho. Administrator Brandon Marquez was contacted but Administrator Marquez did not answer the call. Licensee Sandy Zhao was contacted and informed of the visit.

The following Plan of Correction (POC)s were cleared at the time of the visit:
The licensee was cited on 10/28/2024 for 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. Licensee Zhao submitted proof of carbon monoxide installed at the facility at Plan of Correction (POC) date 10/29/2024. LPA Brown provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 10/28/2024 for CCR 87705 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. Licensee Zhao submitted proof of working auditory device or other staff alert feature to monitor exits to LPA Brown on 10/29/2024, prior to POC due date. LPA Brown provided a clearance letter for this deficiency during the visit.

The following deficiency were not cleared during the time of the visit:

The Licensee was cited on 10/28/2024 for CCR 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. Plan of Correction was ***Continuation on LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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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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: 11/07/2024

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to train all staff on CCR 87309(a). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days.

The Licensee was cited on 10/28/2024 for HSC 1569.618 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. Plan of Correction was to train all staff on HSC1569.618(c)(3). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days.

The Licensee was cited on 10/28/2024 for CCR 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. Plan of Correction was to train all staff on CCR 87465(a)(4). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days.

The Licensee was cited on 10/28/2024 for CCR 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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. Plan of Correction was to train all staff on CCR 87465(a)(5)(A). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days.

The Licensee was cited on 10/28/2024 for CCR 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. Plan of Correction was to submit proof of Resident #2 (R2) medical appointment date to complete the required medical assessment for R2. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. ***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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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: 11/07/2024

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The Licensee was cited on 10/28/2024 for CCR 87608 Postural Support (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. Plan of Correction was to submit proof that Resident #2's full bed rail was removed. Also, Licensee was informed to submit R2 letter/waiver with doctor's written order to CCLD for approval if they prefer R2 to have full bed rail. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. In addition, per records review, the facility was cited for the same regulations within 12-month period for CCR 87608 (a)(5)(B) for facility visits on 07/01/2024 and 10/28/2024. Civil penalty will be issued today, 11/07/2024 with the amount of $250.00 per repeat violation within 12-month period.

The Licensee was cited on 10/28/2024 for CCR 87705 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. Plan of Correction was 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. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days.

The Licensee was cited on 10/28/2024 for CCR 87705 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. Plan of Correction was to submit Resident #2 (R2) medical appointment date to complete the required annual medical assessment for resident with dementia to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. ***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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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: 11/07/2024

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The Licensee was cited on 10/28/2024 for CCR 87307 Personal Accommodation and Services (d)The following space and safety provisions shall apply to all facilities:(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. Plan of Correction was to obtain and install night lights to hallways and passages to nonprivate bathrooms and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day.

The Licensee was cited on 10/28/2024 for HSC 1569.618 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. Plan of Correction was to hire an additional Administrator to ensure that Admistrator's at the facility during working hours as required and submit proof to LPA Brown. Civil penalty will be assessed in the amount of $100 per day for ten (10) days for Repeat Violation on HSC 1569.618(a) assessed on 10/28/2024.

The Licensee was cited on 10/28/2024 for CCR 87219 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. Plan of Correction was to submit a monthly planned activities for residents socialization to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day.

The Licensee was cited on 10/28/2024 for HSC 1569.695 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. Plan of Correction was to conduct the required fire and earthquake drill and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day.

***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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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: 11/07/2024

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The Licensee was cited on 10/28/2024 for HSC 1569.695 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. Plan of Correction was to review and sign the Emergency Disaster Plan and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day.

An exit interview was conducted where this report (LIC809), LIC421FCs, and Appeal Rights were discussed and provided to Sahian Suarez Camacho.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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