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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209439
Report Date: 06/06/2025
Date Signed: 06/06/2025 07:40:00 PM

Document Has Been Signed on 06/06/2025 07:40 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HAPPY LOVING HOME CARE LLCFACILITY NUMBER:
107209439
ADMINISTRATOR/
DIRECTOR:		CAMILO, WILJEN CORDEROFACILITY TYPE:
740
ADDRESS:2699 ALAMOS AVE.TELEPHONE:
(360) 305-2726
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Administrator: Wiljen CamiloTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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On 6/6/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Irene Pinondang, LPA was granted entry. 4 residents were present during inspection. Staff (S1) Rulet Salgado

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed. 1 resident’s medications were observed unlocked in kitchen cabinet. Clients’ MARS was reviewed. Multiple medications observed not initialed by staff on 6/6/25. Fire extinguisher reviewed with a purchase date of: 12/30/23 and does not expire for 5 years. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 105.6 to 106.5 degrees F in 2 bathrooms. No fire drill conducted by staff.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 37 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. Samples of clients’ files and staff’s files reviewed to have some required documents missing. Technical Support Services recommended and accepted by Licensee.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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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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)
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Document Has Been Signed on 06/06/2025 07:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/06/2025 at 06:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 resident's medications were observed unlocked in kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to have all staff including Licensees and Administrators complete medication training and submit completion cerfificates to CCLD by POC due date.
Type A
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
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 6 out of 6 staff are missing LIC-503 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to have all staff visit primary physician and complete LIC0-503 with TB if needed and submit completed forms to CCLD on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 07:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/06/2025 at 06:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 6 staff is not fingerprint cleared or associated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees that staff will not return to facility until staff is fingerprint cleared, entered into Guardian, associated with facility and all LIC forms are complete. Licensee agrees to submit all LIC forms and fingerprint clearances to CCLD by POC due date.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 6 staff is not associated with facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees that staff will not return until entered into Guardian, associated with facility and all LIC forms are complete. Licensee agrees to submit all LIC forms completed to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 07:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/06/2025 at 06:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87406(a)(1)(B)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (B) Four (4) hours of instruction in medication management, including the use, misuse, and interaction of drugs commonly used by the elderly, including antipsychotics, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 7 out of 7 staff do not have medication completion forms or certicates on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to have all staff including all Administrators complete medication trainng and submit completion forms to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 07:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/06/2025 at 06:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 Resident's MARS was not initialed on current date of 6/6/25 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees that all staff complete medication training and submit completion forms to CCLD by POC due date.
Type A
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 4 residents are missing LIC-625 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to complete all LIC-625 forms and submit to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 07:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/06/2025 at 06:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.313
Regulations
Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient’s rights form, the facility’s policy concerning family visits and other communication with resident clients and shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 4 residents are missing LIC-601 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee agrees to complete LIC-601 and submit to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HAPPY LOVING HOME CARE LLC
FACILITY NUMBER: 107209439
VISIT DATE: 06/06/2025
NARRATIVE
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The following deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Civil penalties issued for staff not being fingerprinted and/or associated to facility.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 6/20/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020)

A copy of this report with 9102 and appeal rights were provided to S1, whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC809 (FAS) - (06/04)
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