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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 11/17/2023
Date Signed: 11/17/2023 11:23:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/15/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231115131734
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:
11/17/2023
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Yun Ok Kim, StaffTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility failed to provide resident records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA was granted entry by staff, Yun Kim. Licensee, Eunice Kim, arrived shortly after to assist with the visit.

LPA toured the facility, interviewed the licensee, and reviewed Resident #1’s (R-1) file.

Regarding allegation – Facility failed to provide resident records. It is alleged on November 13, 2023, the facility was sent a formal request via federal express to make available the records of Resident #1 (R-1). The formal request was made by R-1’s legal representative to arrange for photocopies within 2 working days. As of today, the documents had not been provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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 3
Control Number 28-AS-20231115131734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/17/2023
NARRATIVE
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LPA interviewed the licensee who stated she did not sign any federal express delivery this week nor received any mail via federal express. She stated she will check with staff and the mailbox again. LPA verified with legal representative that they did not receive any returned mail and confirmed that the federal express package was left at the facility’s front door on 11/14/23. Based on information gathered, the licensee did not provide the records promptly. Therefore, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights.

An exit interview was held. A copy of this report along with 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: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20231115131734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
HSC
1569.269(a)(21)
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1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have...(21)To have prompt access to review all of their records...not to exceed two business days...
This requirement is not met as evidenced by:
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The licensee shall develop a plan to get the records to the legal representative and provide proof to show records were given to them. This POC is due 12/1/23.
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The licensee did not provide Resident #1's record to legal representative within 2 working days which poses a potential personal rights risk to resident 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3