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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602403
Report Date: 06/27/2023
Date Signed: 06/27/2023 04:40:31 PM


Document Has Been Signed on 06/27/2023 04:40 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:
06/27/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Jung KimTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/27/2023 at 8:34am. LPA was met by Licensee Jung Kim and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for two (2) hospice residents.

LPA OBSERVATIONS: Tour began at 9:15am and was led by licensee. The facility is a single-story building located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Staff living corridors is currently not occupied.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA Ramirez observed kitchen cabinets near stove to contain caked-yellowish and brown splatter stain. LPA Ramirez observed the ceiling above the stove area to contain red and yellow splatter. LPA Ramirez did not observe sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in bottom kitchen cabinet, to be inaccessible to four (4) out of four (4) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) residents in care. Kitchen sink water temperature was measured at 113.8 degrees F.

· Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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Document Has Been Signed on 06/27/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, proof of liability insurance did not meet the above mentioned limits, the licensee did not comply with the section cited above in 4 out of 4 residents and guests, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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Licensee agreed to submit plan by 6/28/23 to address liability insurance. Proof of liability insurance that meets liability limits per HSC 1569.605 must be submitted to LPA by 7/5/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, kitchen cabinets contained caked yellowish and brown spatter stain, 3-inch crack in bedroom #4, 3x3 inch circular hole on shared bathroom#2, overgrowth of weeds and grass in backyard, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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Licensee will clean and disinfect surrounding kitchen cabinets above stove and ceiling, repair crack on wall of bedroom #4, repair hole shared bathroom #2, rid backyard of weed and grass overgrowth. LPA Ramirez will return to the facility to ensure corrections have been made.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee/Administrator Kim could not provide LPA Ramirez with proof of renewed certificate, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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Licensee/Administrator will submit proof of Administrator certificate renewal to LPA Ramirez via email. Licensee/Administrator will maintain certification as required.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(C)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (C) Date(s) of attendance; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not record complete dates regarding training, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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Licensee will ensure full dates are recorded on all future staff required training. Licensee will develop a plan and submit to LPA by 7/11/23 via email.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez did not observe sufficent two day supply of perishable foods for four residents, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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Receipt from grocery store with sufficent perishable food for 4 residents for a minimum of two days, must be submitted via email to LPA.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee could not provide LPA Ramirez with proof of any drill, the licensee did not comply with the section cited above in 4 out of 4 residnets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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Licensee will provide plan to address quartely drill. Licensee will submit final plan and proof of drill by 7/11/23 via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2023
NARRATIVE
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· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Resident Rooms 1 - 4: Bedroom 1 is currently shared and has a private bathroom. LPA Ramirez observed bedroom #1 to contain the required furnishings, linen and lighting. Resident bedroom #2 and #3 are private rooms. LPA Ramirez observed bedroom #2 and #3 to contain the required furnishings, linen, and lighting. Bedroom #4 is shared and LPA Ramirez observed the required furnishings, linen and lighting. LPA Ramirez observed a 3-inch crack inside bedroom #4 wall, near door entry.

· Bathrooms: Private bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 107.4 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 113.1 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed a 3x3 inch circular hole located in shared bathroom #2, behind bathroom door and was exposing drywall.

· Centrally Stored Medications: LPA observed cabinet located in dining room area to be locked and inaccessible to residents. LPA reviewed six (6) out of six (6) resident medications and Medication Administration Record (MAR). LPA Ramirez observed some irregularities on MAR for Resident #1 (R1) and Resident #2 (R2).

· Backyard: LPA Ramirez observed overgrowth of weeds and grass. LPA Ramirez observed multiple beds of plants and vegetables growing throughout backyard. LPA observed plenty of seating and shade. No large bodies of water were observed.

LPA observed carbon monoxide in hallways. Smoke detector was tested during visit. Administrator certificate 6029285740 was observed for Jung Kim with an expiration date of 05/15/22. Proof of fire and earthquake drill could not be provided. Staff files are maintained at facility. Thirteen (13) staff files (S1 – S13) were reviewed. Verification of staff training and orientation is missing complete date(s) of attendance. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. LPA Ramirez reviewed and obtained a copy Infection Control Plan. Licensee provided LPA Ramirez is a copy of liability insurance, however, it does not meet the liability limits. LPA Ramirez observed posted Emergency Disaster Plan.

Deficiencies are being cited during visit. Exit interview was conducted with Licensee Kim and a copy of this report, 809-D and appeals rights were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6