197607034-7-8-2021-28-AS-NWEY-C4R29K-20210708171205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 07/08/2021
Date Signed: 07/08/2021 05:12:10 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 MANOR		FACILITY NUMBER:	197607034
ADMINISTRATOR:	KUN HU		FACILITY TYPE:	740
ADDRESS:	15602 BELSHIRE AVENUE		TELEPHONE:	(562) 926-1289
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	49	CENSUS: 19	DATE:	07/08/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jerry Lo		TIME COMPLETED:	05:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Proof of Corrections(POC) visit and met with Office Manager Jerry Lo and discuss the purpose for todays visit which is to verify/confirm that one of the Type A deficiency during the case management visit conducted on 07/02/2021 have been corrected/cleared. On 07/02/2021 deficiency was cited as follows: 1). Type A, 87202(a)(2)-Fire Clearance. Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department... This evidence has not been met as required by: The facility license was approved to retain 1 bedridden resident and currently LPAs observed there to be 2 bedridden residents(room 15 and room 10) residing in the facility. This poses a health and safety risk. Immediate civil penalty will be assessed. The Licensee/Administrator will immediately relocate one of the bedridden residents to the designated bedridden room(room 11) today. Plan of Correction. Licensee/Administrator is contact the fire department Fire Marshal provide information, submit LIC 200 and facility sketch(identify the location for bedridden residents) to the licensing department immediately and/or by the next business day. Office manager Jerry Lo advised that he contacted the fire department and received instructions on how to proceed. Continued on LIC 809C.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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 2

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
	VISIT DATE: 07/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/26/21, LPA Wesley received signed Physicians report dated 06/25/21 from Office Manager Jerry Lo which indicated that both Resident 2(R2) and Resident 3(R3) ambulatory status is bedridden in which the facility was only granted allowance to retain 1 bedridden resident in designated room #11 per the LA County Fire Department Fire Safety Inspector.

On 07/03/21, Office Manager Jerry Lo sent LPA Wesley an email advising that R2 was relocated to room #11 and R3 status is Non-Ambulatory.

During todays visit, LPA Wesley observed that bedridden Resident(R2) was relocated from bedroom #15 to the approved designated bedridden room(#11) on 07/03/21, and was informed that Resident(R3) obtained an additional Physician's report dated 07/03/2021 which indicates that Resident 3(R3) is non ambulatory. Office Manager Jerry Lo advised that a copy of the LIC 200 and facility sketch was sent to CCLD on 07/07/21 via certified mail. LPA Wesley received copies of the current Physician's report for R3 and a copy of the documents that were mailed to CCLD to request additional bedridden capacity. This deficiency was cleared on 07/03/21 and there will be no additional civil penalties given for this deficiency.

There were no additional deficiencies cited during todays visit. Exit interview conducted and a copy of the report was given to Office Manager Jerry Lo.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2