197610100-1-7-2024-31-AS-JGTN-CZ9SJM-20240107125523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610100
Report Date: 01/07/2024
Date Signed: 01/07/2024 12:56:07 PM

Document Has Been Signed on 01/07/2024 12:56 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HAPPY PLACE ELDER CARE		FACILITY NUMBER:	197610100
ADMINISTRATOR:	JAVIER, HERMAN B.		FACILITY TYPE:	740
ADDRESS:	23609 DAISETTA DRIVE		TELEPHONE:	(661) 505-7600
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	6	CENSUS: 6	DATE:	01/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Herman Javier - Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan met with the Administrator Herman Javier for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. At 9:01 AM, A tour of the physical plant was conducted at 10:30am and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage cabinet located in the hallway. The facility has seven (7) bedrooms and three (3) bathrooms. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory and a hospice waiver for four (4). Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and inter connected and observed to be operational. The facility is equipped with sprinkler system. The fire extinguisher was located in the kitchen and observed to be filled and current. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. (continued to LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY PLACE ELDER CARE	FACILITY NUMBER: 197610100
	VISIT DATE: 01/07/2024

NARRATIVE

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(continued from LIC 809)

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in garage. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. The swimming pool is appropriately fenced and was observed to be locked during visit. The garage is attached to the home and was locked and inaccessible to residents during the visit. The garage is also used as a stock room for emergency foods and PPE and laundry area.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 112.5°F to 118.9°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed. Three (3) out of six (6) residents had no physician's report on file. Staff records: LPA conducted a complete file review of staff record. Staff #1 (S1) has no fingerprint clearance. Two (2) staff had no first aid training certificate on file.

Disaster drill was last conducted on 10/19/2023. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Civil penalty assessed. Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/07/2024 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY PLACE ELDER CARE	FACILITY NUMBER: 197610100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, S1 is currently working without fingerprint clearanc which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2024
	Plan of Correction
1 2 3 4	Cleared during visit. The administrator called another caregiver to cover the shift and sent S1 home.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/07/2024 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY PLACE ELDER CARE	FACILITY NUMBER: 197610100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

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:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3out of 6 residents did not have physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	The administrator agreed to obtain LIC 602 for all three residents and submit a copy of LIC 602 to CCL on or before the POC date.

Type B

Section Cited

CCR

87411(c)(1)

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies such as American Red Cross This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 1 out of 3 staff did not have first aid training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	The administrator agreed to obtain first aid training for all the staff and submit a copy to CCL on or before the POC 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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

LIC809 (FAS) - (06/04)

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