331800205-3-29-2023-18-AS-JESL-CQEP6E-20230330110211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800205
Report Date: 03/29/2023
Date Signed: 03/29/2023 12:23:40 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
03/16/2020 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200316122125

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:	12:04 PM
MET WITH:	Brandon Marquez, Acting Administrator		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Staff did not provide resident’s medication as prescribed.
Staff did not refill resident’s medication in a timely manner.
Staff are not properly labeling food items.
Hazardous chemicals are accessible to residents.
Facility is not observing proper food storage.

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; Staff did not provide resident’s medication as prescribed. Licensing Program Manager (LPM) Joel Esquivel met with acting Administrator Brand to discuss the allegation noted. Acting Administrator denied staff did not provide resident’s medication as prescribed. Administrator stated that staff would provide care as needed and medication was dispensed as prescribed by the physician.

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-20200316122125

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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The facility has been closed as of November 4, 2021. LPM was unable to interview staff, or residents. Due to the lack of evidence and unable to interview staff or residents the allegation is thereby deemed as Unsubstantiated.
Regarding allegation; Staff did not refill resident’s medication in a timely manner. Licensing Program Manager (LPM) Joel Esquivel met with acting Administrator Brandon Marquez to discuss the allegation noted. Acting Administrator denied staff failed to refill resident’s medication in a timely manner. Administrator stated that staff would provide care as needed and medication was dispensed as prescribed by the physician and ordered in a timely manner. The facility has been closed as of November 4, 2021. LPM was unable to interview staff, or residents. Due to the lack of evidence and unable to interview staff or residents the allegation is thereby deemed as Unsubstantiated.
Regarding allegation; Staff are not properly labeling food items. Licensing Program Manager (LPM) Joel Esquivel met with acting Administrator to discuss the allegation noted. Acting Administrator denied that Staff are not properly labeling food items. Administrator stated that staff place a label on each container of leftover food to be sure that food it not eaten after expiration date. The facility has been closed as of November 4, 2021. LPM was unable to interview staff, or residents. Due to the lack of evidence and unable to interview staff or residents the allegation is thereby deemed as Unsubstantiated.
Regarding allegation; Hazardous chemicals are accessible to residents. Licensing Program Manager (LPM) Joel Esquivel met with acting Administrator to discuss the allegation noted. Acting Administrator denied that Hazardous chemicals are not accessible to residents. Administrator stated that staff would use chemicals for cleaning and would lock the items as soon as not needed. The facility has been closed as of November 4, 2021. LPM was unable to interview staff, residents or review the facility. Due to the lack of evidence and unable to interview staff or residents the allegation is thereby deemed as Unsubstantiated.

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)

Page: 2 of 3

Control Number 18-AS-20200316122125

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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Regarding allegation; Facility is not observing proper food storage. Licensing Program Manager (LPM) Joel Esquivel met with acting Administrator to discuss the allegation noted. Acting Administrator denied Facility is not observing proper food storage. Administrator stated that staff place a label on each container of leftover food to be sure that food it not eaten after expiration date. The facility has been closed as of November 4, 2021. LPM was unable to interview staff, residents or review the facility. Due to the lack of evidence and unable to interview staff or residents the allegation is thereby deemed as 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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