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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 04:24:31 PM


Document Has Been Signed on 06/27/2023 04:24 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jung KimTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced case management visit to the facility. The purpose of today’s visit was to serve the Order to Licensee of Immediate Exclusion from Facility for Staff #1 (S1). An investigation by the California Department of Social Services was conducted and it was determined that S1 violated California Code of Regulations Title 22 for personal rights.

On today's visit LPA met with Licensee Jung Kim and explained the reason for the visit. Licensee was provided with copies of the Order to Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion letters and Government Code 11522.

Exit interview held. A copy of the report was provided to Licensee Jung Kim.

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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