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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 06/15/2021
Date Signed: 06/15/2021 02:39:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARDINAL YU-PIN MANORFACILITY NUMBER:
197607034
ADMINISTRATOR:KUN HUFACILITY TYPE:
740
ADDRESS:15602 BELSHIRE AVENUETELEPHONE:
(562) 926-1289
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:49CENSUS: 20DATE:
06/15/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jerry LoTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nicol Wesley and Luis Mora conducted an unannounced Annual Continuation inspection at the facility and met with Licensee Kun (Wendy) Hu and Administrator Jerry Lo and explained the purpose for todays visit. The facility phone number is 562 926 1289.

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A pre-screening area with PPE supplies was observed upon entry into the facility.

LPAs conducted a complete tour of the facility. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPAs observed 12 fire extinguishers throughout the facility. The licensee and administrator was requested to resubmit the facility mitigation plan report by June 15, 2021, to avoid citations.

Administrators certificate for Kun(Wendy) Hu #6000702740 expires on 10/10/2021.

During todays visit, LPAs tested the water temperature which measured 118.4 degrees F, and reviewed a random selection of staff and resident files. The facility will arrange for residents to be assessed and provide updated medical assessments for all residents(specifically Residents #1-#4), prior to close of business on 06/18/2021.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8) on the attached LIC 809D. Appeal rights given.

Exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARDINAL YU-PIN MANOR
FACILITY NUMBER: 197607034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2021
Section Cited

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement was not met as evidenced by:
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LPAs observed a chain and pad lock on the iron exit gate located at the entrance of the facility. This poses a health and safety issue to the residents in care.
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***This deficiency was cleared at the time of visit.***

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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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