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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:03:14 PM


Document Has Been Signed on 07/03/2024 04:03 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: 4DATE:
07/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Licensee Jung H KimTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez met with Licensee Jung Hyun Kim and Staff John Kim at Monterey Park Regional office to discuss validity of CPR/First Aid training of Staff#1 (S1). On 6/25/23, LPA Ramirez conducted Case management visit in regards to a homicide that took place at the facility on 6/24/23. During staff file review, LPA Ramirez observed S1's CPR/First Aid training certificate. LPA Ramirez contacted the CPR/First Aid vendor and it was revealed the CPR/First Aid certificate for S1 was issued on 6/25/23. S1 was already in police custody on 6/24/23. CPR/First Aid certificate LPA Ramirez observed on 6/25/23, was not authentic according to the National CPRFoundation.

One deficiency is being cited. See 809-D. Exit interview was conducted. A copy of this report 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: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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 07/03/2024 04:03 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: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
87405(h)(8)

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(h) The administrator shall have the responsibility to:(8) Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. This requirement was not met as evidence by:
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Licensee will certify all training will be authenticated and verified.
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Licensee provided unauthentic CPR/First Aid training for S1.
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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: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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