331800205-7-27-2021-18-AS-NBRN-C5MSUT-20210806141137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800205
Report Date: 07/26/2021
Date Signed: 07/27/2021 12:38:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200102142520

FACILITY NAME:	HAPPY LIFE HEALTH CARE		FACILITY NUMBER:	331800205
ADMINISTRATOR:	ESTER HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	30667 BROOKSTONE LN		TELEPHONE:	(818) 267-0352
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 0	DATE:	07/26/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sandy Zhau		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Residents were left with unauthorized adult in the facility
Residents were not fed.
Resident was left in a soiled diaper.

INVESTIGATION FINDINGS:

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On 7/26/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a phone visit for the purpose of delivering findings to the above allegations. The facility is closed. The LPA spoke with Sandy Zhau and explained the nature the call.

The Department investigated the allegations and revealed the following:
On 1/1/20 between 6:00 PM and 9:00 PM, residents were provided care and supervision from a neighbor who was not trained to provide care, was not fingerprinted or associated to the facility. An interview with the neighbor confirmed that they were only there to provide supervision for 3 hours until the administrator arrived. The neighbor stated that she did not change or feed any of the residents. Resident 1 (R1) required a diaper change and was not fed between 5:00 PM and 9:00 PM. Interviews with the administrator and R1 confirmed this information. Based on observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted where this report, 9099D, LIC 811 and appeal rights were provided to the administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

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 18-AS-20200102142520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAPPY LIFE HEALTH CARE	FACILITY NUMBER: 331800205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/20/2021 Section Cited CCR 87411(g)(1)	1 2 3 4 5 6 7	PERSONNEL REQUIREMENTS- GENERAL Prior to employment or initial presence in the facility, all employees .. .subject to a criminal record review shall: Obtain a CA clearance or a criminal record exemption as required by law...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will ensure residents are provided care and supervision from staff who have been properly trained, fingerprinted and associated to the facility.
	8 9 10 11 12 13 14	Based on interviews, the licensee failed to ensure residents were cared for by a fingerprint cleared individual. On 1/1/20 a neighbor provided supervision for residents from 6p-9p at the request of the administrator Sandy Zho until she arrived. (continued in next box)	8 9 10 11 12 13 14	This poses an immediate health and safety risk to residents in care.
Type B 07/20/2021 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	MANAGED INCONTINENCE The licensee shall be responsible for ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall ensure that residents who require continent care are provided routine checks. The licensee will provide a diaper log for R1 to the department by the POC date.
	8 9 10 11 12 13 14	Based on interviews, the facility failed to ensure R1 was changed out of a soiled diaper for over an hour. The neighbor providing supervision to the residents was not trained to provide incontinent care. This poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20200102142520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAPPY LIFE HEALTH CARE	FACILITY NUMBER: 331800205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2020 Section Cited CCR 87555(b)(1)	1 2 3 4 5 6 7	GENERAL FOOD SERVICE REQUIREMENTS The following food service requirements shall apply: Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall ensure that all residents are provided 3 meals and snacks each day.
	8 9 10 11 12 13 14	Based on interviews, the facility failed to ensure R1 was provided with dinner between 6p and 9p on 1/1/20. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC9099 (FAS) - (06/04)

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