198602403-5-17-2021-28-AS-MVAO-C5AV78-20210726161043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 05/17/2021
Date Signed: 05/17/2021 04:12:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210114135428

FACILITY NAME:	HAPPY HOME CARE FOR ELDERLY		FACILITY NUMBER:	198602403
ADMINISTRATOR:	JUNG HYUN, KIM		FACILITY TYPE:	740
ADDRESS:	23801 SAPPHIRE CANYON RD		TELEPHONE:	(909) 217-2011
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Eunice Kim		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff is not accomodating the family to talk to the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer was met by administrator Eunice Kim and discussed the purpose of today's visit.

The investigation consisted of the following: On 1/19/21, LPA Spencer conducted the initial visit virtually and took a tour of the physical plant. During the course of the investigation, LPA interviewed the administrator, staff #1 (S1), staff #2 (S2), and residents #1-8 (R1-R8). R3 is no longer a resident and could not be reached and R2 could not complete interviews due to dementia. LPA reviewed facility records including the staff roster, resident roster, admissions agreement and for R3: facility discharge papers and face sheet.

***See continuation of narrative on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210114135428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAPPY HOME CARE FOR ELDERLY	FACILITY NUMBER: 198602403
	VISIT DATE: 05/17/2021

NARRATIVE

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During interviews, reporting party (RP) stated that since her mother R3 moved into the facility she has not been able to talk to her due to various excuses that she is not available to talk. The administrator stated that family members can call either her cell phone or the facility landline to talk to residents. She stated that R3 moved out of the facility on 12/22/20 because the responsible party wanted to move her to a different facility and that is why family members were not able to reach the resident. The administrator stated that residents can have cell phones except those with dementia who can communicate with family using the land line. S1 and S2 stated that family members of residents call often and use either the landline or administrator cell phone. R1, R4, R5, R6, R7, and R8 stated that their family members call her them often and they reach them on the facility telephone. R1, R4, R7, and R8 stated that they have a personal cell that they use but family can also reach them on the landline. All residents interviewed stated that their family has not had trouble reaching them.

LPA confirmed the facility land line phone number and observed that it was in working order. The admissions agreement also states that residents have private telephone service and that facility encourages regular communication with family. A review of the facility discharge papers shows that R3 moved out on 12/22/20.

Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) areUnsubstantiated.

An exit interview was conducted with Administrator Eunice Kim and a hard copy of the report was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

LIC9099 (FAS) - (06/04)

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