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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 06/30/2023
Date Signed: 06/30/2023 10:15:11 AM


Document Has Been Signed on 06/30/2023 10:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HAPPY HOME CARE FOR ELDERLYFACILITY NUMBER:
198602403
ADMINISTRATOR:JUNG HYUN, KIMFACILITY TYPE:
740
ADDRESS:23801 SAPPHIRE CANYON RDTELEPHONE:
(909) 396-1645
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
06/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Jung KimTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit on 6/30/23 at 8:35 am to issue a $500 civil penalty. LPA Ramirez was greeted by Licensee/Administrator Jung Kim and LPA explained the purpose of the visit.

Case Management Findings:

On 6/25/23 RM Ramirez and LPA Ramirez conducted a Case Management visit to perform a health and wellness check on residents in care and to gather information regarding the two (2) recent deaths of Resident #1 (R1) and Resident #2 (R2) on 06/24/23. Copies of pertinent documents for Staff #1 (S1) and interview of staff on 6/25/23, revealed Licensee Jung Kim failed to obtain required criminal record clearance or a criminal record exemption from the State Department of Social Services before S1’s gainful employment at the facility, direct contact with residents in the facility and residing in the facility. Medication Administration Record (MAR) for the month of June 2023 for R1 and R2 appear to record S1’s signature/or initials starting 6/1/23 and on various other days till 6/23/23. LPA Ramirez compared MAR to “Staff Annual Education, Staff Continuing Education, Staff Initial Training, and On-Site Orientation sheets S1 signed/or initialed by S1 and recorded in S1’s facility personnel file. Interview with Licensee Jung Kim on 6/25/23 revealed S1 began employment at the facility on 6/1/23 however, the State of California Department of Justice did not formally issue a DOJ APPLICANT FINGERPRINT RESPONSE letter clearing S1 till 6/16/23. It was revealed S1 worked at the facility without criminal background clearance for a total of fifteen (15) days.

A $500 civil penalty is being issued. Exit interview is being conducted with Licensee Jung Kim and a copy of this report, 809-D, LIC 421BG, and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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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Document Has Been Signed on 06/30/2023 10:15 AM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HAPPY HOME CARE FOR ELDERLY
FACILITY NUMBER: 198602403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2023
Section Cited
CCR
87355(e)(1)

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87355
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:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidence by:
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Licensee shall certify in writing to this licensing agency, all future staff will be subject to a criminal clearance and obtain clearance before staff begins employment, resides at facility or has direct contact with residents in care. LIC 421BG-Civil Penalty of $500 was assessed on 6/30/23.
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Licensee Jung Kim failed to obtain required criminal record clearance or a criminal record exemption from the State Department of Social Services before S1’s gainful employment at the facility, direct contact with residents in the facility and residing in the facility.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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