331880822-6-4-2024-56-AS-KCLS-DADRB2-20241025125159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880822
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:09:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2024 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240530093547

FACILITY NAME:	KUN BAI CARE #2 HOME		FACILITY NUMBER:	331880822
ADMINISTRATOR:	BRANDON MARQUEZ-GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	4091 ELDERBERRY RIDGE		TELEPHONE:	(909) 994-6199
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 2	DATE:	06/04/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Israel Ortiz, Staff		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident fell due to staff neglect
Staff did not check on residents in a timely manner
Staff are not ensuring residents are fed
Staff left residents soiled for an extended period of time
Staff are not ensuring the facility is clean
Staff are not ensuring residents have clean towels
Staff did not ensure medication was properly stored
Staff did not ensure bathroom was not in disrepair
Staff inappropriately recorded resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with staff Ortiz and allowed entry. Staff Ortiz phoned licensee Sandi Jhao, who was interviewed and explained the elements of the complaint. Because Jhao was not available, she allowed for staff Ortiz to sign off on this report.

Regarding the allegation that resident fell due to staff neglect; Staff interviews could not conclude that any resident had fallen due to neglect. The facility is staffed and small enough to notice if someone had fallen. There is no record of residents falling due to neglect. Resident #1 (R1) and R2 are currently residing in the home state that the facility staff treat them well and care for their needs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240530093547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: KUN BAI CARE #2 HOME	FACILITY NUMBER: 331880822
	VISIT DATE: 06/04/2024

NARRATIVE

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Regarding the allegations that staff did not check on residents in a timely manner; LPA observed residents in a common area watching television with staff nearby in the kitchen area in an open floor plan. LPA observed staff checking in on the resident during time of visit.

Regarding the allegation that staff are not ensuring residents are fed; LPA arrived just after breakfast was concluded. Interviews with R1 and R2, stated that they are fed and well taken care of. LPA observed left over meal on the stove, which staff was in the process of cleaning up.

Regarding the allegation that staff left residents soiled for an extended period of time; LPA interview with R1 and R2 state they are changed by staff when soiled. LPA observed outside agency arrive to bath and change R1 during time of visit.

Regarding the allegation that staff are not ensuring the facility is clean; LPA toured the facility and observed that the facility was clean and being cleaned during time of inspection. Resident's rooms were found to be clean during time of visit.

Regarding the allegation that staff are not ensuring residents have clean towels; LPA observed clean washed towels in the laundry area.

Regarding the allegation that staff did not ensure medication was properly stored; Staff showed LPA where the resident's medication was stored. LPA observed the medication stored in a locked cabinet in the living room area.

Regarding the allegation that staff did not ensure bathroom was not in disrepair; LPA observed facility bathrooms and found to be in working order with no observance of any type of disrepair

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240530093547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: KUN BAI CARE #2 HOME	FACILITY NUMBER: 331880822
	VISIT DATE: 06/04/2024

NARRATIVE

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Regarding the allegation that staff inappropriately recorded resident; LPA tour of the facility observed two (2) cameras in the facility common areas of the living room and hallway. No cameras were found in the resident's bedrooms or bathrooms, which would be inappropriate.

Based on the information obtained there is not enough evidence that resident fell due to staff neglect, staff did not check on residents in a timely manner, staff are not ensuring residents are fed, staff left residents soiled for an extended period of time, staff are not ensuring the facility is clean, staff are not ensuring residents have clean towels, staff did not ensure medication was properly stored, staff did not ensure bathroom was not in disrepair, staff inappropriately recorded resident. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by staff Ortiz and LPA Prieto and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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