198602403-3-9-2023-28-AS-TVAO-CRBT84-20230428142941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602403
Report Date: 03/09/2023
Date Signed: 03/09/2023 01:54:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/03/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230303152941

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: 6	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Jung "Eunice" Kim, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff did not allow resident to have visitors.
Facility staff did not safeguard resident's belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with Administrator, Eunice Kim. The purpose of the visit was explained.

LPA toured the facility and obtained a list of residents and staff. LPA also reviewed residents files and obtained copies of Resident #1 (R-1) documents. Interviews were held with the Administrator, 1 Staff, 2 Residents, and family member. R-1 is not longer residing at the facility.

In regards to allegation - Facility staff did not allow resident to have visitors. It is alleged that a family member was denied visitation inside the facility. LPA interviewed the Administrator and another staff during the visit today. The Administrator and staff both denied not allowing any visitations to the facility. Administrator Ms. Kim stated that R-1's family members had visited the facility on different days while R-1 was residing at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230303152941

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/09/2023

NARRATIVE

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R-1 only resided at the facility for a few days and allowed them entry inside the home. Although the facility did not document the dates and times in which R-1's family visited, the administrator showed text messages with the family members allowing them to come to the facility. LPA interviewed R-1's family member who indicated that the staff denied entry to the home on one of the visits and took R-1 out instead. R-1's family member also stated that due to an appointment, it was decided to take R-1 with them rather than to stay there. Administrator and staff deny turning away any visitation of family members when they are present at the front door. LPA interviewed 2 Residents and both stated they get visitors at the home.

In regards to allegation - Facility staff did not safeguard resident's belongings. LPA interviewed the administrator who stated they provide most of the items to the residents, such as a bed, bedding sheets, and personal hygiene products. Administrator stated that the inventory sheet is filled out upon admission and if there are valuables brought in, they are indicated on the Resident Personal Property and Valuables form. Ms. Kim recalled R-1 only bringing in a slipper and clothing but not bedding. LPA interviewed R-1's family member who stated that after discharge, R-1's belongings were returned in addition to the bedding that was requested to be used. Based on information gathered, there is insufficient evidence to support this allegation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted. A copy of this report along with the appeal rights were provided to Administrator Kim.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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