Kun Bai Care #2 Home

Type of visit: Case Management - Deficiencies

On July 27, 2026, Licensing Program Analyst (LPA) Andrew Martinez conducted a unannounced Case Management - Deficiencies inspection visit regarding uncleared deficiencies issued during LPA's prior visit on 04/30/2026. LPA was greeted by, introduced self, and was granted access by House Manager/Caregiver Titus Irungu. At the time of visit there was the only one (1) staff present and three (3) of (3) residents in care. During LPA's prior Case Management - Deficiencies visit on 04/30/2026, a review of the facility's Licensing Information System (LIS) file indicated the facility's annual fees totaling $1,484.00 were outstanding/unpaid. LPA Martinez issued a Type A deficiency with a Plan of Correction (POC) to submit renewal payment in full to Community Care Licensing Division (CCLD) and to submit proof of payment to LPA via email by close of business (COB) on POC due date, 05/01/2026. As for today's review of the facility's LIS file, licensing fees remained unpaid. On arrival, LPA spoke with Licensee Sandy Zhao over the phone indicating the reason for today's visit. Licensee could not definitively recall if renewal fees had been paid or not and indicated to LPA, she needed time to look through her files. Approximately 35-45 minutes later, prior to LPA concluding facility visit, Licensee forwarded a copy of CCLD's payment page showing the total amount of fees of $1,484.00 paid as of 7/27/2026 at 2:32:27 PM for the facility Kun Bai Care #2 Home, facility number #331880822. As proof of payment for all fees being paid in full has been supplied to LPA, no additional deficiency will be issued. LPA shall review the facility's LIS file and clear the deficiency upon verification that facility's LIS file has been updated to show fees are paid in full. An exit interview was conducted where this Facility Evaluation Report (LIC 809) was discussed with and a copy provided to House Manager/Caregiver Titus Irungu.the state’s words, verbatim · CDSS document, Jul 27, 2026

Allegation investigated: Staff is not able to communicate with residents in care.

Regarding the second allegation - Staff is not able to communicate with residents in care: LPA observed S1 was unable to effectively communicate with residents regarding their needs, care, or supervision. LPA attempted to communicate with S1 regarding the allegations mentioned while asking basic questions related to care and supervision. S1 was unable to understand or respond to LPA’s questions in English. LPA made multiple attempts to communicate using simple and direct language; however, S1 was unable to demonstrate an understanding of the questions asked without using a translator application on their cellular device to communicate. S1 telephoned Administrator, Brandon Marquez-Gutierrez (S2), to inform them of LPA's arrival. LPA was informed by S2 that they and Licensee, Sandy Zhao (S3), were unanable to be present at the facility today. LPA's reqeuests had to be translated in Spanish by S2 to S1. Based on investigation, the above allegation is SUBSTANTIATED. A SUBSTANTIATED finding is a finding defined as a violation that has occurred based on the preponderance of available evidence. An exit interview was conducted where this report LIC 9099A, LIC 9099D, and Appeal Rights were discussed and a copies were provided to Caregiver, Rosalimo Sarellano. Substantiatedthe state’s words, verbatim · CDSS document, Apr 30, 2026 · control 56-AS-20260422082110

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 14, 2026

87411(a)Facility personnel shall at all times be... competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines...the facility require... additional staff for the provision of adequate services. Based on observations and attempted interviews, S1 demonstrated an inability to effectively communicate with residents and LPA, impactaing their ability to provide adequate care and supervision to residents, This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Licensee shall ensure that all staff have the ability to effectively communicate with residents and Licensing staff in order to provide adequate care and supervision. Licensee shall submit a written plan to Licensing describing how communication competency will be ensured for all staff along with an updated LIC 500 Personnel Report indicating staff's full names as they appear on Guardian that coincides with written plan to provide adequate care and supervision to residents by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On April 30, 2026, Licensing Program Analyst (LPA) Andrew Martinez conducted a Case Management - Deficiencies inspection while on visit to the facility to conduct a complaint investigation on Control Number 56-AS-20260422082110. Caregiver Rosalimo (S1) was the only staff present at the facility along with three (3) residents in care. During facility tour, LPA observed the facility did not have an Administrator present at the facility. Licensee Sandy Zhao stated that they and their Administrator Brandon Marquez-Gutierrez would not be present at the facility today. A previous licensing report was issued on 06/25/2025 giving notice on the same violation. Due to the facility having been cited for repeating the same violation within 12 months, an immediate civil penalty of $250 is hereby assessed for the day of 04/30/2026. Civil penalties will continue to accrue at the rate of $100.00 per day until the deficiency is corrected in accordance with the California Code of Regulations (CCR), Title 22, Division 6. In addition, LPA observed the following disinfectants, cleaning solutions, and sharp objects either not in locked storage, or left out and unattended: an unattended bottle of disinfectant spray located on the entryway table next to the sign in sheets, an unattended bottle of laundry detergent in the laundry room behind an unlocked door, and two unattended pair of scissors located within an un-lockable drawer to the left of the kitchen refrigerator. A Type A deficiency is being cited as facility staff did not ensure the above items were inaccessible to residents in care posing an immediate health, safety and personal rights risk to persons in care. *** Continued on 809-C *** During a review of the facility's file, CCLD's Licensing Information System (LIS) indicated the facility's annual fees were due on or before 12/31/2025. As of today, fees have not been paid, a late fee was assessed, the current grand total of annual fees to be paid as of 04/30/2025 is $1,484.00 due immediately. A Type A deficiency is being cited. Based on observations and file review, two (2) Type A deficiencies are being cited, as well as civil penalties are being assessed for a repeat violation that was previously cited within the past twelve (12) months. An exit interview was conducted, where this report was discussed and a copy of LIC 809, LIC 809C, LIC-809D, LIC 421FC, and Appeal Rights were provided to Caregiver, Rosalimo Sarellano, at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.168(a) · Plan of correction due date: May 1, 2026

§1569.618 (a) The administrator designated... shall be present at the facility during normal working hours... shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above by not ensuring that the facility Administrator is present at the facility during working hours as required which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Licensee stated additional designees will be assigned to ensure an Administrator(s) can be at the facility during working hours as required. Licensee will submit LIC 308(s) to Licesning and provide proof of submission(s) of LIC 308(s), and updated LIC 500, via email to LPA Martinez by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 1, 2026

87309(a) ... [T]he licensee shall ensure that disinfectants, cleaning solutions,... 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. This requirement is not met as evidenced by: Based on observation, facility staff did not ensure disinfectants, cleaning solutions, and sharp objects were not left unattended or outside of locked storage areas which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Caregiver immediately placed disinfectants, cleaning solutions, and sharp objects in locked storage. Licensee to review cited regulation with facility staff and provide a written statement of understanding to Licensing by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185 · Plan of correction due date: May 1, 2026

1569.185 Fees for license... (a)(1)...After initial licensure, a fee shall be charged... annually... (b)(1)(F) A late fee that represents an additional 50 percent of... current annual fee when a licensee fails to pay... on or before the due date as indicated. This requirement was not me as evidenced by: Based on facility file review, the licensee did not comply with the section cited above by not ensuring the facility licensing fees were been paid to the Department by the due date which poses an immediate health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: LPA advised Licensee facility's annual fees are due to be paid to the Department by POC due date. LPA informed Licensee late fees and/or civil penalties may be assessed if fees not paid in full by POC due date. Licensee to provide proof of payment to LPA via email by close of business on POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Staff Gallegos Luis. Administrator Brandon Marquez and Licensee Sandy Zhao were contacted and informed of the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Hospice waiver for six (6). During today’s inspection there were four (4) residents in care. LPA with staff toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms did not contain a chair. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. Review of residents’ Medication Administration Records (MAR)s revealed that Resident #1 (R1) had not received one of their medications since December 3, 2025, although the physician’s order prescribed the medication to be given daily. Interviews revealed that the medication was being given as needed, as a PRN, rather than being given as prescribed. No pools or bodies of water exist on the premises. Per Licensee Zhao, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC809-C] LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Two deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated, and an exit interview was conducted with Licensee Zhao via telephone and Staff Gallegos Luis, to whom a copy of this report, LIC809-C, LIC809-D and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Staff left resident unattended, covered in urine and blood, for extended periods. Staff did not assist resident in a timely manner. Due to a language barrier, staff can't communicate. Inadequate food service.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with staff Jair Melgarieio Martinez and explained the purpose of the visit. The Administrator Brandon Marquez was also contacted and informed about today’s visit. The investigation consisted of staff interviews, resident interviews and record reviews. For the allegation, Staff left resident unattended, covered in urine and blood, for extended periods. During resident interviews, 4 out of the 4 residents stated they have not been left unattended, covered in urine and blood, for an extended period. During staff interviews, 3 out of the 3 staff stated they have not left their residents unattended, covered in urine and blood for an extend period. LPA Rico conducted a facility tour and did not observe residents covered in urine or blood. Unsubstantiated For the allegation, Staff did not assist resident in a timely manner. During resident interviews 4 out of the 4 residents stated they receive assistance in a timely manner. During staff interviews, 3 out of the 3 staff stated they assist their residents in a timely manner. For the allegation, due to a language barrier, staff can't communicate. During resident interviews 4 out of the 4 residents stated they can communicate with staff members. In addition, R3 and R4 confirmed they prefer to speak Spanish. During staff interviews 3 out of the 3 staff stated they can communicate with their residents. For the allegation, Inadequate food service. During residents’ interviews, 4 out of the 4 residents stated they receive their meals and can request more food. During staff interviews, 2 out of the 2 staff stated they will ensure they have enough food supply. Furthermore, LPA observed the facility adequate food supply for the number of residents. Based on the evidence found during the investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to staff Jair Melgarieio Martinez.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 56-AS-20240624141719

Type of visit: Case Management - Other

Licensing Program Analyst (LP) Mary Rico conducted an unannounced case management visit pertaining to complaint control number 56-AS-20240624141719.LPA Rico met with staff Jair Melgarieio Martinez. The Licensee Sandy Zhao was contacted and informed of the visit. LPA Rico conducted staff interviews, resident interviews, facility tour and record review. During facility tour, LPA Rico observed the facility did not have an Administrator present at the facility. Licensee Sandy Zhao stated that their Administrator and House Manager were off. A pervious licensing report was issued on 10/28/2024 giving notice on the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is correct. In addition, LPA Rico reviewed resident records, LPA Rico observed R1(dementia) did not have their updated medical assessment. A pervious licensing report was issued on 10/28/2024 giving notice on the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is correct. An exit interview was conducted where this report, LIC809, LIC809D, LIC421FC and Appeal Rights were discussed and provided to staff Jair Melgarierio Martinezthe state’s words, verbatim · CDSS document, Jun 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jun 26, 2025

Care of Persons with Dementia(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment.This requirement is not met as evidenced by Based on record review, the licensee did not comply with the section cited above by not ensuring that Resident1 have an annual medical assessment as required for dementia resident which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Licensee stated to submit R1 medical appointment date to complete the required annual medical assessmet for resident with dementia to LPA Rico on Plan of Correction (POC) due date. POC due date 6/26/2025.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.618(a) · Plan of correction due date: Jun 26, 2025

Other Provisions(a) The administrator designated.. shall be present at the facility during normal working hours... shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.This requirement is not met as evidenced by Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the Administrator's present at the facility during working hours as required which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Licensee stated to hire an additional Administrator to ensure that Admistrator's at the facility during working hours as required and submit proof to LPA Rico on Plan of Correction (POC) due date. POC due date 6/26/2025.

Type of visit: POC

On 11/07/2024 at 12:20 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee Sandy Zhao and Administrator Brandon Marquez and reports provided to staff Sahian Suarez Camacho from visit on 10/28/2024. LPA Brown met with staff Sahian Suarez Camacho. Administrator Brandon Marquez was contacted but Administrator Marquez did not answer the call. Licensee Sandy Zhao was contacted and informed of the visit. The following Plan of Correction (POC)s were cleared at the time of the visit: The licensee was cited on 10/28/2024 for HSC 1569.311 Regulations. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. Licensee Zhao submitted proof of carbon monoxide installed at the facility at Plan of Correction (POC) date 10/29/2024. LPA Brown provided a clearance letter for this deficiency during the visit. The Licensee was cited on 10/28/2024 for CCR 87705 Care of Persons with Dementia. (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. Licensee Zhao submitted proof of working auditory device or other staff alert feature to monitor exits to LPA Brown on 10/29/2024, prior to POC due date. LPA Brown provided a clearance letter for this deficiency during the visit. The following deficiency were not cleared during the time of the visit: The Licensee was cited on 10/28/2024 for CCR 87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Plan of Correction was ***Continuation on LIC809C *** to train all staff on CCR 87309(a). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. The Licensee was cited on 10/28/2024 for HSC 1569.618 Other Provisions (c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. Plan of Correction was to train all staff on HSC1569.618(c)(3). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. The Licensee was cited on 10/28/2024 for CCR 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. Plan of Correction was to train all staff on CCR 87465(a)(4). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. The Licensee was cited on 10/28/2024 for CCR 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. Plan of Correction was to train all staff on CCR 87465(a)(5)(A). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. The Licensee was cited on 10/28/2024 for CCR 87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. Plan of Correction was to submit proof of Resident #2 (R2) medical appointment date to complete the required medical assessment for R2. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. ***Continuation in LIC809C*** The Licensee was cited on 10/28/2024 for CCR 87608 Postural Support (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. 5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. Plan of Correction was to submit proof that Resident #2's full bed rail was removed. Also, Licensee was informed to submit R2 letter/waiver with doctor's written order to CCLD for approval if they prefer R2 to have full bed rail. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. In addition, per records review, the facility was cited for the same regulations within 12-month period for CCR 87608 (a)(5)(B) for facility visits on 07/01/2024 and 10/28/2024. Civil penalty will be issued today, 11/07/2024 with the amount of $250.00 per repeat violation within 12-month period. The Licensee was cited on 10/28/2024 for CCR 87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. Plan of Correction was to schedule a staff to work the night shift as required for facility with dementia residents and submit an updated staff schedule and Personnel Report (LIC500) to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. The Licensee was cited on 10/28/2024 for CCR 87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. Plan of Correction was to submit Resident #2 (R2) medical appointment date to complete the required annual medical assessment for resident with dementia to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for ten (10) days. ***Continuation in LIC809C*** The Licensee was cited on 10/28/2024 for CCR 87307 Personal Accommodation and Services (d)The following space and safety provisions shall apply to all facilities:(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. Plan of Correction was to obtain and install night lights to hallways and passages to nonprivate bathrooms and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day. The Licensee was cited on 10/28/2024 for HSC 1569.618 Other Provisions (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. Plan of Correction was to hire an additional Administrator to ensure that Admistrator's at the facility during working hours as required and submit proof to LPA Brown. Civil penalty will be assessed in the amount of $100 per day for ten (10) days for Repeat Violation on HSC 1569.618(a) assessed on 10/28/2024. The Licensee was cited on 10/28/2024 for CCR 87219 Planned Activities. (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets. Plan of Correction was to submit a monthly planned activities for residents socialization to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day. The Licensee was cited on 10/28/2024 for HSC 1569.695 Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. Plan of Correction was to conduct the required fire and earthquake drill and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day. ***Continuation in LIC809C*** The Licensee was cited on 10/28/2024 for HSC 1569.695 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. Plan of Correction was to review and sign the Emergency Disaster Plan and submit proof to LPA Brown. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for one (1) day. An exit interview was conducted where this report (LIC809), LIC421FCs, and Appeal Rights were discussed and provided to Sahian Suarez Camacho.the state’s words, verbatim · CDSS document, Nov 7, 2024

Type of visit: Required - 1 Year

On 10/28/2024 at 11:20 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and two (2) residents present. Administrator Brandon Marquez and Licensee Sandy Zhao was contacted and informed of the visit. Administrator Marquez was not at the facility during the visit. LPA Brown explained the purpose of the visit to staff Sahian Suarez Camacho.. The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory. The facility has six (6) Hospice Waiver. The current census is two (2) residents. LPA Brown was accompanied by staff Camacho to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). The facility is equipped with operating smoke detectors but LPA Brown observed no carbon monoxide at the facility. Deficiency will be issued. LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 107 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as mattresses and storage space, however, LPA Brown observed missing one (1) chair and one (1) lamp in resident #1 (R1) and resident #2 (R2) bedroom. Technical Violation issued. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and the customized bathroom tiles in the resident bathrooms. ***Continuation in LIC809C *** Also, LPA Brown observed Resident #2 (R2) with full bed rails and Staff #2 S2) reported to LPA Brown that R2 is not on Hospice Care and no written order from R2 physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R2's full bed rails. Deficiency will be issued. In addition, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. Furthermore, during the tour of the facility, LPA Brown observed one (1) scissor, four antibiotic ointments in R1 and R2 bedroom, not locked and accessible to residents in care. Also, LPA Brown observed two (2) gallons of bleach, three (3) bottles of cleaning solutions, one bottle of laundry detergent in the garage, not locked and accessible to residents in care and one (1) scissor in the hallway closet, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. However, LPA Brown observed the facility's auditory device to alert staff to monitor exits is in disrepair. Deficiency will be issued. Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: LPA Brown observed no administrator present at the facility during normal working hours. Deficiency will be issued. Also, LPA Brown observed one (1) staff working at the facility and per staff interview and records review, no staff's scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued.. ***Continuation in LIC809C *** ***This is an amendment copy of the form LIC809C issued today, 10/28/2024*** Record Review: LPA Brown observed Infection Control Plan maintained at the facility. However, LPA Brown observed the liability insurance maintained at the facility is for Worker's Compensation and Employers' Liability and it does not cover injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three (3) million dollars ($3,000,000) in the total annual aggregate caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Deficiency will be issued. Licensee updated the required liability insurance during the visit today, 10/28/2024 and provided LPA Brown a copy. LPA Brown observed no fire and earthquake drill conducted at the facility. Deficiency will be issued. LPA Brown observed that the facility did not review the emergency disaster plan annually as evidenced of the Licensee/Administrator did not sign the emergency disaster plan this year. Deficiency will be issued. LPA reviewed two (2) resident files for admission agreements, updated physician reports, Pre-placement Appraisals, Centrally Stored Medication List, Preplacement Needs and Services Plan. LPA Brown observed Resident #2 (R2) physician report does not have physician signature and signature date and per documents review, R2 was admitted to the facility on 03/29/2023. Deficiency will be issued. LPA Brown observed Resident #2 (2) Physician Assessment indicated dementia but R2 does not have the required annual medical assessment for residents with dementia. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results and LPA Brown observed Staff #2 (S2) First Aid/CPR certification expired on 10/22/2024. Deficiency will be issued. During medication audit, LPA Brown observed that facility staff did not assist Resident #1 (R1) with one (1) medication. Deficiency will be issued. Also, LPA Brown observed Resident #2 (R2) with one (1) medication without R2's physician authorization. Deficiency will be issued. Per records review, the facility was cited for the same regulations within 12-month period for CCR 87309(a), CCR 87458(a) and HSC 1569.618(a). Civil penalty will be issued today, 10/28/2024 with the amount of $250.00 per repeat violation within 12-month period. An exit interview was conducted where this report (LIC809), LIC809D, LIC421FC, LIC9102TV and LIC9102TA and Appeal Rights were discussed and provided to Sahian Suarez Camacho.the state’s words, verbatim · CDSS document, Oct 28, 2024

The state marks this report as 16 pages; the online copy we transcribed has 12. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that the cleaning supplies were inaccessible to residents. Staff did not ensure that medications were properly stored and locked.

On 07/01/2024, Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced to initiate and deliver findings for the above allegations. LPA Brown was greeted and granted entry by Staff #2 (S2) and LPA Brown explained the purpose of the visit. Administrator Brandon-Marquez Gutierez was contacted and informed of the vsit. The investigation consisted of observation, interviews and a review of pertinent documentation. The investigation was conducted by LPA Melody Brown. The investigation consisted of observations and interviews with relevant parties. The allegation indicates that Staff did not ensure that the cleaning supplies were inaccessible to residents. LPA Brown obtained evidence to corroborate the allegation above. During the quick tour of the facility on 07/01/2024, LPA Brown observed multiple bottles of cleaning supplies and chemicals under the kitchen sink, not locked and accessible to residents in care. S2 immediately locked the multiple bottles of chemicals under the sink with a padlock. S2 reported to LPA Brown that they were not aware that chemicals must be locked and inaccessible to residents. **Continuation in LIC9099C** Substantiated The second allegation indicates Staff did not ensure that medications were properly stored and locked. During the quick tour of the facility on 07/01/2024, LPA Brown observed residents medications were kept in a cabinet in the corner of the living room but not locked and accessible to residents in care. S2 immediately locked the residents medication during the facility visit. S2 reported to LPA Brown that they were not aware that resident medications must be locked and not accessible to residents. Based on LPA Brown’s observations and interview, the preponderance of evidence standard has been met, and therefore the above allegations of Staff did not ensure that the cleaning supplies were inaccessible to residents (Allegation #1), Staff did not ensure that medications were properly stored and locked (Allegation #2) are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D. Per records review, the facility was cited for the same regulation within 12-month period for CCR 87465(h)(2) on 10/10/2023, therefore civil penalty will be issued today, 07/01/2024 with the amount of $250.00 for repeat violation within 12-month period. An exit interview was conducted where this report, LIC9099, LIC9099D, LIC421FC and Appeal Rights were discussed and provided to Sahian Suarez Camacho. and they always provide them drinks with meals. During the visit on 07/01/2024, LPA Brown observed S2 providing water to drink to Resident #2 (R2) and Resident #3 (R3). The second allegation indicates Staff did not ensure that the facility was kept clean. Interviews with two (2) of two (2) residents indicated that staffs at the facility are cleaning the home twice a day and they both reported that staffs at the facility always maintains the facility clean. Interview with S2 indicated that they are cleaning the facility everyday to keep it clean and S2 reported to LPA Brown that there's no incident that a staff did not ensure that the facility's kept clean. During the facility visit on 07/01/2024, LPA Brown observed the facility was kept clean by S2. Based on the evidence, the allegations that Staff did not ensure that the resident was hydrated (Allegation #1), Staff did not ensure that the facility was kept clean (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Sahian Suarez Camacho.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 56-AS-20240624141719

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Jul 2, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Based on observation, and interview, the Licensee did not comply with the section cited above by not locking the multiple bottle of cleaning solutions, and chemicals under the kitchen sink making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown on Plan of Correction (POC) due date. Licensee locked the multiple bottle of chemicals/cleaning solutions during the visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 2, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, and interview, the Licensee did not comply with the section cited above by not ensuring that residents centrally stored medications are kept in a safe and locked place that is not accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to train all staff on CCR 87465(h)(2) and submit proof of all staff training log to LPA Brown on POC due date. Licensee locked the medicine cabinet where the resindents medications are stored during the visit.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 07/01/2024 at 08:50 AM, Licensing Program Analyst (LPA) Melody Brown met with staff Sahian Suarez Camacho to initiate Case Management Visit. Administrator Brandon Marquez was contacted and informed of the visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. During the tour of the facility, LPA Brown observed five (5) knives in the kitchen drawer, not locked and accessible to residents in care. Deficiency will be issued. Also, LPA Brown observed Resident #3 (R3) with full bed rail and per documents review, R3 was not on hospice and no written documentation from R3's physician indicating the need for full bed rail and no full bed rail exemption was submitted to Community Care Licensing Division (CCLD). Deficiency will be issued. Moreover, LPA Brown, observed that there's no Administrator present at the facility during working hours and LPA Brown requested S2 to contact Administrator Marquez and Administrator Marquez reported to LPA Brown unable to to go to the facility during the visit for personal reasons. Also, S2 reported that Administrator Marquez was not checking or visiting the facility. S2 added that Administrator Marquez was always at their Fontana facility. Deficiency will be issued. Also, LPA Brown observed no Administrator present at the facility during working hours. Deficiency will be issued. In addition, per documents review, LPA Brown observed R3 admitted to the facility on 03/29/2023 but with no completed and updated Medical Assessment or Physician Report (LIC602) as form LIC602 on R3's file does not have Physician Signature and signature date. Deficiency will be issued. Per records review, the facility was cited for the same regulations within 12-month period for HSC 1569.618(a) and CCR 87468(a), civil penalty will be issued today, 07/01/2024 with the amount of $250.00 per repeat violation within 12-month period. An exit interview was conducted where this report, LIC809, LIC809D, LIC421FC and Appeal Rights were discussed and provided to Sahian Suarez Camacho.the state’s words, verbatim · CDSS document, Jul 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 2, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not storing the five (5) knives observed in the kitchen cabinet where it's inaccessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to train all staff on CCR 87309(a) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Jul 12, 2024

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #3 (R3) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date. Licensee will remove R3 full bed rail and submit proof to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(a) · Plan of correction due date: Jul 16, 2024

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to submit Signed Statement of Understanding on HSC 1569.618(a) and submit to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458(a) · Plan of correction due date: Jul 2, 2024

87458 Medical Assessment a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) has a completed Medical Assessment by R3's Physician prior to acceptance as a resident at the facility as evidenced of R3's Physician Report on file is not complete due to missing Physician signature which pose immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee stated to schedule R3's Medical Assessment and submit proof to LPA Brown on Plan of Correction (POC) due date.

Allegation investigated: 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

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 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 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.the state’s words, verbatim · CDSS document, Jun 4, 2024 · control 56-AS-20240530093547