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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 02/07/2024
Date Signed: 02/07/2024 10:51:27 AM

Unsubstantiated


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
01/31/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240131160707
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:
02/07/2024
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Eunice Kim Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility failed to provide resident's records.
INVESTIGATION FINDINGS:
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On 02/07/2024 at 9:43 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit to investigate the above listed allegation. Upon arrival, LPA met with Staff #2. Shortly after the licensee Eunice Kim arrived and the purpose of the visit was discussed.

During today’s visit, LPA Baptiste obtained a copy of the staff roster, resident roster, formal request from R1’s legal representative, and a copy of the receipt with a date the documents was sent to R1’s legal representative. LPA conducted a tour of the buildings and grounds with Staff #1. LPA Baptiste interviewed the licensee and a total of one (1) staff, who shall be referred to as staff #1(S1). LPA also interviewed R1’s legal representative who shall be referred to as witness #1.

Report continued on 9099c
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
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-20240131160707
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: 02/07/2024
NARRATIVE
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The investigation reveals the following: Regarding “Facility failed to provide resident's records”. It is alleged the facility received a formal request to make R1’s documentation’s available on January 29th, 2024. The request was sent by R1’s legal representative and asked not to exceed two business days. According to the licensee the request arrived on January 30th, 2024, and the documents was sent out January 31st, 2024. S1 corroborated the statement, by adding they received the request and shipped the documents no later than the next day. Witness #1 confirmed they received the documents on February 1st, 2024. LPA reviewed the receipt and confirmed the facility shipped the documents on January 31st and R1’s legal representative was due to receive the documents no later than February 1st, 2024, at 6:00 pm.

Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview conducted with Eunice Kim and a copy of this record provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2