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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:55:41 PM


Document Has Been Signed on 10/10/2023 02:55 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
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: 3DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eunice Kim, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit regarding the death of two Residents. LPA met with Licensee/Administrator, Jung “Eunice” Kim and explained the purpose of the visit.

On 6/24/23, The News reported a double homicide that occurred at the facility. A facility staff arrived in the morning and found 2 residents inside the restroom floor and were unresponsive. The staff immediately called 911 to report the incident. This prompted the department to conduct a visit to the facility. On 6/25/23, Regional Manager Araceli Ramirez and LPA Kimberly Ramirez conducted a health and safety check at the facility and gathered documents pertaining to Resident #1 (R1), Resident #2 (R2), Staff #1 (S1), and Staff #2 (S2). During the visit on 06/25/23, it was discovered that S1 was arrested for the murder of two residents of the facility. Due to the nature of the deaths, the Department of Social Services Community Care Licensing Division Investigation Branch (IB) Investigator, Ryan Miles conducted a further investigation. Investigator Miles interviewed the licensee/administrator, Jung Kim, S1 and S2. Investigator also obtained the L.A. County Sherriff’s report and 911 calls made to the Walnut Sheriff’s Station.

On 8/24/23, Investigator Miles interviewed the suspect while in custody and admitted to the murder of both residents but did not want to go into further details of how the incident occurred. The investigation revealed that S1 started working and residing at the facility on 06/01/23. However, S1’s background clearance did not clear until 06/16/23. Therefore, the licensee allowed S1 to begin working and residing at the facility prior to completing a criminal record clearance. On 06/30/23, the licensee was issued an immediate civil penalty of $500 for allowing S1 to work in the facility prior to obtaining a background clearance.

Based on the interviews conducted and supporting documents provided, there is sufficient evidence to support the allegation of Conduct Inimical, therefore, the finding is substantiated. An Immediate Civil Penalty of $500 is being issued today. Refer to LIC421IM. The issuance of an additional Civil Penalty is being assessed based on health and safety code 1569.49(e) if the department determines the death of the client is due to neglect.

An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to the licensee.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 10/10/2023 02:55 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
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2023
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs...delivered by staff...
This requirement is not met as evidenced by:
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The licensee shall ensure each staff member is qualified to provide care and supervision to all residents. The licensee shall provide in-service training to all staff regarding the care plan for each resident and ensuring there is sufficient staffing to meet their needs. This POC is due by 10/11/23.
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Based on interviews, the licensee did not ensure that the residents are provided with care, supervision, and services that meet their needs which poses an immediate health, safety, and personal rights to residents in care.
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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: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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