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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 07/12/2021
Date Signed: 07/12/2021 12:46:04 PM



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
05/13/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200513100445
FACILITY NAME:HAPPY HOME CARE FOR ELDERLYFACILITY NUMBER:
198602403
ADMINISTRATOR:JUNG HYUN, KIMFACILITY TYPE:
740
ADDRESS:23801 SAPPHIRE CANYON RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 3DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner.
Facility staff did not distribute residents medication as prescribed.
Facility staff did not follow physicians orders.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with the Facility Administrator and discussed the pupose of today's visit.

On 05/20/2020, LPA initiated this investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted this investigation telephonically with the Facility Administrator. LPA obtained relevant documentation for this complaint investigation

During this investigation, LPA interviewed the Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). LPA also obtained relevant documentation.

***Refer to LIC 9099C for the continuation of this report**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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 5
Control Number 28-AS-20200513100445
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: 07/12/2021
NARRATIVE
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Allegation: Facility staff did not seek medical attention in a timely manner. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Interviewed Staff indicated R-1 received medical visits for wound care. Visits were conducted on 04/14/2020, 04/17/2020, 04/21/2020, 04/24/2020, 04/28/2020 and 05/01/2020. Per Facility Administrator, there is no visitor logs for R-1 other than the dates noted above. Per Facility Administrator, R-1 received televisit consultations prior to visits, however, Facility Administrator was only able to provide evidence of communication via text for 04/08/2020, 04/10/2020 and 04/11/2020. Facility Administrator was unable to provide evidence on any televisits nor visits prior to 04/08/2020. Per Facility Administrator, due to COVID-19, R-1 was only receiving tele-visits and visits to this home. Per Facility Administrator, S-1 was changing R-1's gauze and applying ointment since 03/29/2020 up until discharge. R-1 was admitted to this facility on 03/28/2020 from a Skilled Nursing Facility for wound care. Interviews and reviewed documentation corroborate this allegation.

Allegation: Facility staff did not distribute residents medication as prescribed. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Facility Administrator indicated R-1 had ointment to be applied to the wound when R-1 was discharged from the Skilled Nursing Facility to this facility. Facility Administrator did not have any supporting evidence for this treatment/medication. Facility Administrator provided a prescription order for R-1 dated 04/21/2020 for ointment. There are no medication orders for wound treatment medication prior to 04/21/2020 on file. Interview and reviewed documentation corroborate this allegation.

Allegation: Facility staff did not follow physicians orders. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Per Facility Administrator, S-1 was changing R-1's gauze and applying ointment since 03/29/2020 up until discharge. R-1 was discharged from this home on 05/01/2020. Per R-1's file review, there were no orders on performing routine wound care prior to 04/14/2020. Interviews and reviewed documentation corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200513100445
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: 07/12/2021
NARRATIVE
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Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.

Deficiency as per California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.

An exit Interview was conducted with the Administrator, a copy of this report and Appeal Rights were provided

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20200513100445
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited
CCR
87468.1(a)(16)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This standard is not met as evidence by: R-1 was admitted to this facility on 03/28/2020 for wound care. Visits were conducted on 04/14/2020,
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Adm to provide training on Personal Rights of Residents to all staff and provide written statement as to how staff will adhere by these regulations. Adm to also submit proof of training in a form of a log which contains staff names, date of training, duration of training, presenter of training and curriculum used for this training to LPA Irra by POC due
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04/17/2020, 04/21/2020, 04/24/2020, 04/28/2020 and 05/01/2020. Per Adm, R-1 received televisit consultations prior to visits. Adm was only able to provide evidence of communication via text for 04/08/2020, 04/10/2020 and 04/11/2020. Adm was unable to provide evidence on any televisits nor visits prior to 04/08/2020.
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date of 07/13/2021.
Type A
07/13/2021
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care:(e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This standard is not met as evidence by:
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Continuation on next page.
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Adm indicated R-1 had ointment to be applied to the wound when R-1 was discharged from the Skilled Nursing Facility to this facility. Adm did not have any supporting evidence for this treatment/medication. Adm provided a prescription order for R-1 dated 04/21/2020 for ointment. There are no medication orders for wound treatment medication prior to 04/21/2020 on file.
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Continuation on next page.
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: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20200513100445
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited
CCR
87465(e)
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This is a continuation of 87465(e). Per Adm, S-1 was changing R-1's gauze and applying ointment since 03/29/2020 up until discharge. R-1 was discharged from this home on 05/01/2020. Per R-1's file review, there were no orders on performing routine wound care prior to 04/14/2020.

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Adm to provide training on Incidental Medical and Dental Care to all staff and provide a written statement as to how staff will adhere by these regultations. Adm to also submit proof of training in a form of a log which contains staff names, date of training, duration of training, presenter of training and curriculum used for this training to LPA Irra by POC due date
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of 07/13/2021.
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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: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5