197607034-7-12-2024-28-AS-AREA-D6ZS7H-20240709133735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607034
Report Date: 07/09/2024
Date Signed: 07/12/2024 09:18:43 AM

Document Has Been Signed on 07/12/2024 09:18 AM - 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 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: 26	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Wendy Hu		TIME COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced Annual/Required inspection to Cardinal Yu-Pin Manor. Upon arrival LPA was greeted by Administrator Wendy Hu and explained the reason for the visit. This facility is licensed to serve (49) Non- Ambulatory residents age 60 and above. The facility may retain one bedridden resident in room#11. Hospice waiver approved for five (5) residents.

The facility consists of a single level building with 29 resident bedrooms, with attached 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. Resident bedrooms appeared to be in compliance. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen.

The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, and shower chair. The water temperature measured at 114.5*F-120 *F in bathrooms tested, which meets title 22 guidelines. The smoke detectors/fire alarms were being professional tested during visit, and observed to be working properly. There were fire extinguishers located throughout the facility, fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. The pantry was well stocked, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the facility.

The outdoor grounds were toured and inspected, and the patio was well maintained with exercise a shaded seating area accessible for client use. A portion of staff and resident files were reviewed. LPA also reviewed a portion of resident medications.

Deficiency on attached 809-D. Exit interview conducted. A copy of report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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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Document Has Been Signed on 07/12/2024 09:18 AM - 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

This requirement is not met as evidenced by: LPA Rea observed that the facility did not have a carbon monoxide detector as required.
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview conducted, the administrator did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Administrator will purchase a carbon monoxide detector for the facility, and send proof of purchase to LPA by POC due date.

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.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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