<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:49:13 PM

Document Has Been Signed on 07/24/2025 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARDINAL YU-PIN MANORFACILITY NUMBER:
197607034
ADMINISTRATOR/
DIRECTOR:		KUN HUFACILITY TYPE:
740
ADDRESS:15602 BELSHIRE AVENUETELEPHONE:
(562) 926-1289
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 49CENSUS: 28DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Xia QinFen CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 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) Sakinah Madyun and Out Of Class-Licensing Program Manager(LPM) Mary Flores conducted an annual visit. LPA and LPM met with Xia QinFen and explained the reason for the visit.

This facility is licensed to serve (49) Non- Ambulatory resident's age 60 and above. The facility may retain one bedridden resident in room#11. Hospice waiver approved for five (5) resident's. The facility consists of a single level building with (35) resident bedrooms, with private bathrooms, an activity room, chapel, laundry room, common shower area, facility kitchen and dining room area. There are (2) offices, a medication room, and a courtyard.

LPA and LPM toured the facility with Xia QinFen and observed the following:
Infection Control: Facility does not have a copy of a Infection Control Plan. All staff have a TB clearance.
Operational Requirements: Facility maintains a plan of operation and a fire clearance. Facility is operating within the limitations of their license. They have (5) resident's under hospice. A current liability insurance was observed and a copy was obtained.
Physical Plant/Environmental Safety: During facility's tour LPA and LPM observed all common areas in good repair. A total of (5) random residents' rooms were observed. Each room was furnished, with sufficient lighting, and bedding supplies, with the exception of bedroom #29 bathroom's light. Water temperature was tested in each resident's bathroom and tested between 110.0 - 122.2 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and skid mats.
(CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 10
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)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARDINAL YU-PIN MANOR
FACILITY NUMBER: 197607034
VISIT DATE: 07/24/2025
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
Dining room has a covered fireplace. LPA and LPM observed a can of WD40 above the fire extinguisher by the front entrance and (2) bottles of cockroach spray in the laundry area which is accessible to residents.
Resident Rights/Information: License, Ombudsman, personal rights posters were posted in entrance of facility hallway. The Let us Know (PUB 475) was not observed.
Food Services: LPA and LPM toured the commercial kitchen and observed food supplies for at least (2) days of perishables and (7) days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. Currently there are no residents with modified diets.
Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication room. LPA and LPM reviewed medication for (5) resident's. No residents have taken PRN medication in the last month.
Resident Records/Incident Reports: LPA and LPM reviewed (5) resident's files, each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Resident #2 file was observed with Physician's Report dated 8/1/23 and Appraisal dated 7/5/23. Resident #3 file was observed missing an Appraisal. Interviews were attempted to be conducted with (4) resident's.
Disaster Preparedness: LPA and LPM reviewed Emergency Disaster Plan LIC 610E (10/03) which is not the current revision. Emergency Drills are conducted quarterly, last Emergency Drill was conducted on 2/21/25. Facility has fire extinguishers and fire sprinkler system throughout as well.
Staffing: Administrator certificate was reviewed for Kun Hu #70000337400 exp. date: 10/10/2025. CPR/First Aid training was observed for (5) staff files. Call buttons were tested for (3) resident's and they were responded to immediately.
Personnel Records/Staff Training: LPA and LPM reviewed (5) staff files. Files include; TB clearance, background clearance, personnel record, and training. Health screenings were not observed for all (5) staff. Interviews were conducted with (3) available staff.
Planned Activities: LPA and LPM observed activity calendar and staff communicated what additional activities are held at the facility.

Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Kun Hu and Pinshi Liu a copy of this report LIC 809D and Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 07/24/2025 03:49 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 07/24/2025 at 02:28 PM
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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in bathroom in room #29 water temperature tested at 112.2 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
1
2
3
4
Administrator will adjust water temperature and certify in writing that they will ensure water temperature is within the required 105-120 degrees F by POC due date 7/25/25.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation], the licensee did not comply with the section cited above in LPA observed a can of WD40 on top of fire extinguisher by the front entrance and 2 bottles of cockroach spray in the laundry area which is accessible to residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
1
2
3
4
Administrator will ensure that all poisonous solutions are locked and inaccessible to the residents will provide trainings to staff and certify it in writing and submit copies to the department by POC due date 7/25/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 07/24/2025 03:49 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 07/24/2025 at 02:28 PM
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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in5 out of 5 staff files did not have a health screening LIC 503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
1
2
3
4
Administrator will email a copy of health screening for 5 staff by POC due date 7/31/25.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in training was last provided to staff on 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
1
2
3
4
Administrator will conduct training with the staff and submit a copy of 20 hours of training to the department by POC due date 8/7/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 07/24/2025 03:49 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 07/24/2025 at 02:28 PM
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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident 2 appraisal was last conducted on 7/5/23 and Resident 3 did not have an appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
1
2
3
4
Administrator will provide a copy of current appraisals for Resident #2-#3 by POC due date 7/31/25.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident #2 did not have a current medical assessment last conducted on 8/1/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
1
2
3
4
Administrator will obtain a current medical assessment for Resident #2 and submit a copy to the department by POC due date 8/7/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 07/24/2025 03:49 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 07/24/2025 at 02:28 PM
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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in facility does not have a current Emergency Disaster plan LIC610E(03/19) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
1
2
3
4
Administrator will submit a copy of current Emergency Disaster plan LIC610E(03/19) to the department by POC due date 7/31/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10