198602403-9-9-2021-28-AS-NGAA-C6PVNJ-20210909163512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:35:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	JUNG HYUN, KIM		FACILITY TYPE:	740
ADDRESS:	23801 SAPPHIRE CANYON RD		TELEPHONE:	(909) 396-1645
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Jung Hyun Kim		TIME COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/9/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced site visit for the annual inspection. LPAs met with Jung Hyun Kim (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 6 ambulatory of which 3 may be non-ambulatory. Hospice waiver for 2. LPAs observed COVID19 informational and symptom posters by front door and throughout facility. There is hand sanitizer available throughout facility. The facility is located in a residential area. A tour of the single-story facility includes: Living room, den, garage/laundry/Storage, 4 bedrooms, 3 bathrooms, tv room, kitchen, dining area. The following was observed: Facility is operating within capacity and not beyond any conditions and limitation on the license. No pools and bodies of water, no firearms. Comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature measures at 109.4 degrees F in bathroom #1. There are presence of grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid mats or strips. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. Minimum of one week supply of nonperishable foods and 2 days of perishable foods observed. Perishable foods and beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. The facility has sufficient staff to provide the services needed to meet resident needs. Staff in sufficient numbers to meet the needs of all dementia residents and to escort residents who leave the facility. Items that could constitute a danger is stored inaccessible to dementia residents. Staff assisting residents with ADLs has required training. Staff has Criminal Record Clearance. Resident have a medical assessment, signed by a physician within the last year. Facility has a disaster and mass casualty plan in writing and be readily available. No persons have a prohibited health conditions. Centrally stored medicines is kept in a safe and locked place. Carbon Monoxide detector and smoke alarm were observed to be functioning properly. LPAs observed fire extinguisher fully charged. CONTINUED 809-C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021

NARRATIVE

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The following deficiencies were observed at time of visit:

LPAs observed both outside gates with a lock that can only be unlocked with a numerical code
LPAs observed medication discrepancies for R1, R1 is being administered Vitamin D without a prescription, Vitamin C without a prescription label, and Probiotic without a prescription label.
LPAs observed medication discrepancies for R2, R2 Nattokinase 2,000 FUS without a label and C-1000 Antioxidant without a label.

Exit interview conducted, a copy of report and appeal rights provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed both outside gates locked with a locking mechanism that can only be opened with a numerical code. Based on observation and interview, the licensee did not comply with the section cited, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2021
	Plan of Correction
1 2 3 4	Administrator removed locks at time of visit, no further action needed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed medication discrepancies for R1, R1 is being administered Vitamin D without a prescription, Vitamin C without a prescription label, and Probiotic without a prescription label. LPAs observed medication discrepancies for R2, R2 Nattokinase 2,000 FUS without a label and C-1000 Antioxidant without a label. Based on observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2021
	Plan of Correction
1 2 3 4	Administrator will provide photo proof of medication with prescription label for R1 and R2 and will provide proof of prescription for Vitamin D by doctor for R1.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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