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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:57:23 PM


Document Has Been Signed on 06/20/2022 02:57 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, 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: 26DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Administrator Kun HuTIME COMPLETED:
03:11 PM
NARRATIVE
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On 6/20/22 at 11:41 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting a required annual inspection. On today's visit LPA met with Administrator, Kun “Wendy” Hu who assisted with the visit.

The Facility is licensed to served 49 non- ambulatory residents age 60 and above. Facility may retain one bedridden resident in room #11. Hospice wavier approved for five (5) residents.

The facility consists of a single level building with resident bedrooms, each having its own bathroom. A library/activity room, chapel, laundry room, facility kitchen and dining room. The facility also has an administration office and medication room and guest restroom. There is a large patio area with sufficient seating and shaded area for resident use.

LPA discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, staff files, and resident medications.



Report Continued on 809C
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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 4


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: 06/20/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. Passageways and exits are free of obstruction. Hand sanitizing gel and masks located at the entrance of each room. Bathrooms are cleaned with the required grab bars and no skid matts. LPA observed communal bathroom with no skid matts. Infection control signs posted throughout the facility. The hot water temperature measured at 110.7-119.4 degrees F. The facility temperature at the time of the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed and it appears to be given as prescribed. Staff file reviewed to have health screening. During file review LPA observed Staff 1(S1) not associated to the facility. LPA verified with CCL office and staff 1 is cleared but not associated to this facility. LPA found S1 was disassociated to the facility on 5/13/2020. Infection control signs posted throughout the facility and LPA observed 30 days’ supply of PPE’s. Carbon Monoxide and smoke detectors tested in working order. Last disaster drill conducted March 25th, 2022. Administrator certificate # 6000702740 expire 10/10/2023.

Pursuant to Title 22 code of regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D & LIC421 BG): Exit Interview Conducted with Administrator / Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/20/2022 02:57 PM - It Cannot Be Edited

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: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Administrator will ensure bathrooms has skid matts by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/20/2022 02:57 PM - It Cannot Be Edited

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: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)

Criminal Record Clearence
Prior to working, residing or volunteering in a licensed facility, all individuals subject to a crimal record review shall obtain criminal record clearence or criminal record exeption.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in which S1 is not associated the facility and has work at the facility since 5/13/2020, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Administrator will ensure S1 will be associated to the facility before S1 resume work. Administrator will submit confirmation through email when S1 is associated to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4