Cardinal Yu-Pin Manor

Type of visit: Case Management - Annual Continuation

On 8/11/23 at 9:05 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced annual continuation inspection to Cardinal Yu-Pin Manor. Upon arrival LPA was greeted by Direct Support staff and explained the reason for the visit. The office manager Julie Chen arrived and assisted with the visit. During todays visit LPA conducted interviews and finalized care tools. There will be citations issued today based observations from the initial inspection conducted on 7/27/2023. During the initial visit the bathrooms contain a working toilet, basin, shower with grab bar, and shower chair. In Bathroom #11, #26, and #28 skid matts/strips were missing. The water temperature measured at 113.5*F-125.0*F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Office manager / Appeal Rights Provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Aug 11, 2023

Type of visit: Required - 1 Year

On 7/27/23 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Cardinal Yu-Pin Manor. Upon arrival LPA was greeted by Direct Support 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 last emergency disaster/fire drill was conducted on 7/2/2023. The Administrator Certificate expires on 10/10/2023 #6000702740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (7) staff files, (10) resident files, medications, and medication administration records for (10) residents. The facility consists of a single level building with 29 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. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, and shower chair. In Bathroom #11, #26, and #28 skid matts/strips were missing. The temperature measured at 113.5*F-125.0*F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. The smoke detectors were tested and observed to be working properly. The carbon monoxide detector was tested and functioning 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. (Report continued on LIC809C.) The outdoor grounds were toured and inspected, and the patio was well maintained with exercise a shaded seating area accessible for client use. . Upon return LPA will conduct interviews, Training review, Finalize care tools and issue citations. Exit interview conducted with Wendy Hu, Administrator, a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2023

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Jun 20, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Nicol Wesley and Bonnie Tao conducted an unannounced case management inspection and met with Administrator Kun Wendy Hu and explained the purpose for todays visit. Prior to the visit, a risk assessment was completed. The facility phone number is 562 926 1289. During todays visit, LPA Wesley and Tao toured the physical plant, and interviewed a random selection of residents. There were no health and safety concerns observed. During the visit Accountant Julie Chen arrived and joined the visit and discussed the completion of the TSP(Technical Support Program) engagement services that was completed as of 11/23/21. There were no deficiencies cited. A copy of this report was given during the exit interview. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 14, 2021

Allegation investigated: 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.

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 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.the state’s words, verbatim · CDSS document, Aug 10, 2021 · control 28-AS-20210427113757

Type of visit: POC

Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Proof of Corrections(POC) visit and met with Office Manager Jerry Lo and discuss the purpose for todays visit which is to verify/confirm that one of the Type A deficiency during the case management visit conducted on 07/02/2021 have been corrected/cleared. On 07/02/2021 deficiency was cited as follows: 1). Type A, 87202(a)(2)-Fire Clearance. Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department... This evidence has not been met as required by: The facility license was approved to retain 1 bedridden resident and currently LPAs observed there to be 2 bedridden residents(room 15 and room 10) residing in the facility. This poses a health and safety risk. **Immediate civil penalty will be assessed**. The Licensee/Administrator will immediately relocate one of the bedridden residents to the designated bedridden room(room 11) today. Plan of Correction. Licensee/Administrator is contact the fire department Fire Marshal provide information, submit LIC 200 and facility sketch(identify the location for bedridden residents) to the licensing department immediately and/or by the next business day. Office manager Jerry Lo advised that he contacted the fire department and received instructions on how to proceed. Continued on LIC 809C. On 06/26/21, LPA Wesley received signed Physicians report dated 06/25/21 from Office Manager Jerry Lo which indicated that both Resident 2(R2) and Resident 3(R3) ambulatory status is bedridden in which the facility was only granted allowance to retain 1 bedridden resident in designated room #11 per the LA County Fire Department Fire Safety Inspector. On 07/03/21, Office Manager Jerry Lo sent LPA Wesley an email advising that R2 was relocated to room #11 and R3 status is Non-Ambulatory. During todays visit, LPA Wesley observed that bedridden Resident(R2) was relocated from bedroom #15 to the approved designated bedridden room(#11) on 07/03/21, and was informed that Resident(R3) obtained an additional Physician's report dated 07/03/2021 which indicates that Resident 3(R3) is non ambulatory. Office Manager Jerry Lo advised that a copy of the LIC 200 and facility sketch was sent to CCLD on 07/07/21 via certified mail. LPA Wesley received copies of the current Physician's report for R3 and a copy of the documents that were mailed to CCLD to request additional bedridden capacity. This deficiency was cleared on 07/03/21 and there will be no additional civil penalties given for this deficiency. There were no additional deficiencies cited during todays visit. Exit interview conducted and a copy of the report was given to Office Manager Jerry Lo.the state’s words, verbatim · CDSS document, Jul 8, 2021