198602403-7-12-2021-28-AS-MVAO-C5ANYE-20210726105238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 07/12/2021
Date Signed: 07/12/2021 12:10:59 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
12/24/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20201224141659

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: 3	DATE:	07/12/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Kim Jung Hyun - Administrator		TIME COMPLETED:	09:11 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff unlawfully evicted a resident
Staff did not issue a refund

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations.

The investigation consisted of the following: On 12/31/20 LPA Flores conducted telephone interview with the administrator,and requested copies of Staff and Resident roster, Admissions Agreement, Face Sheet, Physician's Report, Needs and Care Assestment Plan, Financial and Admission Policies for 2 residents currently residing at facility and 1 resident who resided at facility until 2 weeks ago, and a Copy of Refund to be emailed to the LPA. On 7/12/21 LPA Flores reviewed resident #1's(R1) file, and requested copies of Admission agreement, resident record, resident property and values, eviction procedure, admission policy and procedure, resident appraisal, appraisal needs and services plan, centrally stored medication, medication administration record, physician's report, assisted living waiver information notice (ALW), admission record from Alcott Rehabilitation Hospital, ALW individual plan, text conversation between family and administrator.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20201224141659

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: 07/12/2021

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
26
27
28
29
30
31
32

The investigation revealed the following: Regarding allegation: Staff unlawfully evicted a resident. It is alleged resident #1(R1) was kicked out due to their inability to care for the elderly with dementia. On 7/12/21 LPA Flores reviewed R1's file and observed an admission agreement signed on 12/8/21. R1's physician report dated 12/11/20. R1's file contained a letter with effective date 12/22/21 and states "note: Federal regulations require that your transfer or discharge be made for one of the following reasons: the transfer to discharge is appropriate because she wants to move to another place." which does not state any of the elements of an eviction letter or state that facility is requesting resident to move out. R1 moved out on 12/22/20 according to the administrator by R1 family representative's choice. LPA reviewed text messages between R1's representative and administrator and found no evidence of facility requesting R1 to move out of the facility.

Based on LPA's file review and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Staff did not issue a refund . It is alleged facility is not willing to refund the 2 weeks of prepaid room & board fee. On 7/12/21 LPA Flores reviewed R1's file and observed an admission agreement signed on 12/8/21 and the agree monthly fee is $1069.72. R1 resided at the facility for 14 days, according to administrator the amount for the 14 days totaled and was charge $499.20 and additional charges for an amount of $35.05. Facility provided R1's responsible party a check for the amount of $499.64 dated 12/24/20. Admissions agreement signed and dated on 12/8/20 by responsible party states on section 8 Refund conditions states "other than this, regardless of the condition, the monthly fee paid in any given month will not be refunded."

Based on LPA's file review and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found UNSUBSTANTIATED

Exit interview was conducted with Kim Jung administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2