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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880822
Report Date: 06/25/2025
Date Signed: 06/25/2025 02:19:57 PM

Document Has Been Signed on 06/25/2025 02:19 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/
DIRECTOR:		BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:4091 ELDERBERRY RIDGETELEPHONE:
(909) 994-6199
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 2DATE:
06/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff-Jair Melgarieio MartinezTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LP) Mary Rico conducted an unannounced case management visit pertaining to complaint control number 56-AS-20240624141719.LPA Rico met with staff Jair Melgarieio Martinez. The Licensee Sandy Zhao was contacted and informed of the visit. LPA Rico conducted staff interviews, resident interviews, facility tour and record review.

During facility tour, LPA Rico observed the facility did not have an Administrator present at the facility. Licensee Sandy Zhao stated that their Administrator and House Manager were off. A pervious licensing report was issued on 10/28/2024 giving notice on the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is correct.

In addition, LPA Rico reviewed resident records, LPA Rico observed R1(dementia) did not have their updated medical assessment. A pervious licensing report was issued on 10/28/2024 giving notice on the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is correct.

An exit interview was conducted where this report, LIC809, LIC809D, LIC421FC and Appeal Rights were discussed and provided to staff Jair Melgarierio Martinez

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/25/2025 02:19 PM - It Cannot Be Edited


Created By: Mary Rico On 06/25/2025 at 10:48 AM
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: 06/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2025
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment.This requirement is not met as evidenced by
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Licensee stated to submit R1 medical appointment date to complete the required annual medical assessmet for resident with dementia to LPA Rico on Plan of Correction (POC) due date.
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Based on record review, the licensee did not comply with the section cited above by not ensuring that Resident1 have an annual medical assessment as required for dementia resident which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 6/26/2025.
Type A
06/26/2025
Section Cited
HSC1569.618(a)

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Other Provisions(a) The administrator designated.. shall be present at the facility during normal working hours... 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 hire an additional Administrator to ensure that Admistrator's at the facility during working hours as required and submit proof to LPA Rico on Plan of Correction (POC) due date.
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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 Administrator's present at the facility during working hours as required which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 6/26/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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