331800205-3-29-2023-18-AS-JESL-CQEP6S-20230330110250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800205
Report Date: 03/29/2023
Date Signed: 03/29/2023 12:22:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2020 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200409100217

FACILITY NAME:	HAPPY LIFE HEALTH CARE		FACILITY NUMBER:	331800205
ADMINISTRATOR:	AHAOMA ONYEBUCHI		FACILITY TYPE:	740
ADDRESS:	30667 BROOKSTONE LN		TELEPHONE:	(818) 267-0352
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	0	CENSUS: 0	DATE:	03/29/2023
		UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Brandon Marquez, Acting Administrator		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care
Staff is sleeping while residents are present

INVESTIGATION FINDINGS:

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On March 29, 2023, Licensing Program Manager (LPM), Joel Esquivel met with acting Administrator Brandon Marquez for an office meeting to discuss the above allegations.
Regarding allegation; Resident sustained an injury from a fall while in care. LPM spoke with acting administrator Brandon Marquez regarding a fall; on or about April 9, 2020 at 2:00 am, emergency personnel arrived at the facility from a 911 call.
Resident #1 (R1) is bedbound, has frequent falls and has Dementia. Administrator stated that resident sometimes gets up without notice and staff is not alerted so they are unable to assist.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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-20200409100217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: HAPPY LIFE HEALTH CARE	FACILITY NUMBER: 331800205
	VISIT DATE: 03/29/2023

NARRATIVE

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Administrator stated that staff conducted body checks every two hours to verify that residents are doing well. R1 passed away on August 27, 2020. The facility had not reported any incidents during the time frame mentioned. It is unclear if R1 was had summoned the staff and provided an opportunity for the staff to assist; as such it is unclear that were negligent at the time of fall(s). Interviews conducted were inconsistent and LPM could not corroborate the information provided, as such the allegation noted above is found to be unsubstantiated. It should be noted that the facility has been closed as of November 4, 2021 initiated by the licensee.
Regarding allegation; Staff is sleeping while residents are present. LPM spoke with acting Administrator Brandon Marquez regarding a fall; on or about April 2020 at 2:00 am, emergency personnel arrived at the facility from a 911 call. R1 is bedbound, has frequent falls and has Dementia. It was reported that Staff was sleeping during the time of emergency personnel visited the facility on or around April 9, 2020. Interviews conducted were inconsistent and LPM could not corroborate the allegation that Staff is sleeping while residents are present; Emergency Personnel stated that since time being so long ago, 911 personnel were unable to remember what staff was present during the visits and could not corroborate that they were sleeping, as such the allegations noted above is found to be unsubstantiated.
An exit interview was conducted, and a copy of this report was provided to the licensee/ Administrator Na Zhao.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC9099 (FAS) - (06/04)

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