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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:07:24 PM


Document Has Been Signed on 09/28/2022 03:07 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
CCLD Regional Office, 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: 6DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Kui YoTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Kui Yo and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.Shortly thereafter Administrator Jung Hyun Kim arrived.
LPA Trueman toured the facility along with Jung Hyun Kim today 9/28/2022 at 2:15 PM and the following was observed: Facility contains 4 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and backyard activity area.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables. Medication for clients were verified as being administered and a 30 day supply on hand.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Temperature checks are conducted 2x a day and logged.
Staff have been trained in hand washing. All staff have criminal clearance.
Staff are sufficient with no shortages and there is a plan to replace workers if ill.
There are rooms available if isolation is needed. Staff wear masks.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. LPA observed outside gate with a lock that can only be unlocked with a numerical code. Deficiency cited on separate 809 and 809 D Case Management Report
Advisory Notice issued during inspection. Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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