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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800205
Report Date: 07/26/2021
Date Signed: 07/27/2021 12:30:54 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
02/18/2020 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200218093944
FACILITY NAME:HAPPY LIFE HEALTH CAREFACILITY NUMBER:
331800205
ADMINISTRATOR:ESTER HERNANDEZFACILITY TYPE:
740
ADDRESS:30667 BROOKSTONE LNTELEPHONE:
(818) 267-0352
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: 0DATE:
07/26/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sandy ZhauTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility has Insufficient staff to meet the residents' needs
Administrator is not on the premise a sufficient number of hours for adequate management of the facility.
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 has investigated the allegations and the following has been determined:
During an interview with the administrator, it was confirmed that the facility was experiencing a staffing shortage due to frequent call offs. The facility has 4 residents and one staff. Resident 1 (R) requires a two person assist. The administrator also confirmed that she has had her father help to assist with the care and supervision of the residents. The father speaks very little English, therefore he will call the administrator on the phone so that she can translate the resident's requests. Based on LPAs 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, LIC 811, 9099D and appeal rights were provided to the administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (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)
Page: 1 of 2
Control Number 18-AS-20200218093944
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
07/26/2021
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:
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The licensee will hire and retain sufficient staff to meet the care needs of all resident, including R1 who requires a two person assist. The licensee will provide proof of staffing to the department by the POC date.
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Based on observation and interview, the licensee failed to ensure that staffing was sufficient. Resident 1(R1) requires a two person assist.

This is an immediate health and safety risk to residents in care.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (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 2