<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 06/25/2023
Date Signed: 06/25/2023 02:30:02 PM


Document Has Been Signed on 06/25/2023 02:30 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:
06/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Jung KimTIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Kimberly Ramirez and Regional Manager (RM) Araceli Ramirez conducted an unannounced Case Management visit to the facility on 06/25/23 and gained entry into the facility at 12:59 pm, to perform health and wellness check and gather information regarding two recent (2) resident deaths at the facility. LPA Ramirez and RM Ramirez were greeted by Administrator Jung H. Kim and explained the purpose of the visit.

The facility is located on a residential street and is a single-story home. LPA Ramirez and RM Ramirez conducted physical plant tour, interviews of Staff #1- 2 (S1- S2), attempted resident interviews #1 -4 (R1 -R4), copies of staff files (S2,S3), copies of resident files (R1-R6), staff roster, resident roster and any other pertinent documents related into this investigation. No immediate hazards were observed during visit.

Additional information is required, and this licensing agency may return to gather additional documentation and interviews. A copy of this report is being provided to Administrator Kim.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1