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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607034
Report Date: 08/10/2021
Date Signed: 08/10/2021 05:00:50 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210427113757
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:
08/10/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Wendy HuTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff failed to supervise resident resulting in multiple falls and injuries.
Facility is not allowing communication between family and resident.
Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Nicol Wesley conducted an unannounced subsequent complaint visit at the facility and met with Office Manager Jerry Lo and Administrator Wendy Hu to explain the purpose for todays visit.

The investigation consisted of the following: During the visit on 07/02/21 LPAs Wesley and Mora obtained additional information and attempted to interview resident #1 but was not successful. On 05/03/2, LPA Wesley conducted a telephonic interview with Administrator Wendy Hu and requested the following documents: staff roster, resident roster, current admission agreement for resident #1, ID page for resident #1, physicians report for resident #1, appraisal needs and services for resident #1, and copies of all special incident reports from January 2021 to present, to be emailed/faxed to Nicol Wesley by 05/05/21.

Regarding allegation: Staff failed to supervise resident resulting in multiple falls and injuries and resident sustained unexplained injury while in care. During the investigation LPA interviewed Administrator, office Manager and staff who informed that they never witnessed resident #1 and that resident #1 has never fallen
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20210427113757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2021
NARRATIVE
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multiple times and sustained any injuries. LPA did not observed any incident reports for resident #1. The Administrator advised that resident #1 is not able to ambulate and is not capable of picking them self up as they are getting weak and unable to move or walk without assistance. Staff has to assist resident #1 with moving around as they use a wheelchair and requires full assistance with elements of daily living. During the interviews with staff they also explained that they never observed any injuries or bruises on resident #1. LPA interviewed other parties who advised that the family were dealing with a dispute and going back in forth as one of the family members wanted resident #1 to be relocated to another facility and the responsible party refused and stated their loved one did not wish to be moved and also that the resident was more compatible in the type of environment that the facility provides. During the interviews with other parties it was communicated that resident #1 can not engage in a full conversation because of the decline in their health condition, and they said the allegations were based on a perception and not actual facts. LPA Wesley attempted to interview resident #1 who answered "no" when they were asked if they had fallen multiple times, had multiple, or any injuries that resulted in them having bruising. Resident #1 answered "yes" when they were asked if they were left unsupervised when they required assistance with elements of daily living. LPA Wesley made several attempts to interview an additional party to gather more information regarding the allegation, but was not successful as they have failed to return my call.

Regarding allegation: Facility is not allowing communication between family and resident. LPA asked resident #1 if they were able to communicate with their family during the pandemic and resident #1 answered "yes." LPA Wesley interviewed other parties who advised earlier during the pandemic they were not able to see their loved one, and said they were able to speak to them as they had a personal cell phone and that the facility did communicate effectively with resident #1's responsible party. The interview also revealed that due to resident #1's health condition, their cellphone was locked as they entered the incorrect password too many times, but they were still able to contact the facility to speak to resident #1. The Administrator said they allowed the family to speak to their love ones when they called as they know it was hard for them since they could not physically see the residents. The Administrator said they are only allowed to communicate the resident's responsible party, or whomever has Power of Attorney to make executive decisions and can not provide information to anyone who is not listed as a responsible party. LPA Wesley made several attempts to interview an additional party to gather more information regarding the allegation, but was not successful as they have failed to return my call. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies were cited during todays visit. A copy of the licensing report was given during the exit Interview.










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

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2