<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600735
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:42:32 PM


Document Has Been Signed on 07/28/2023 05:42 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DOUBLE HAPPINESS CARE HOMEFACILITY NUMBER:
415600735
ADMINISTRATOR:LAU, FLORDELIZAFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRCLETELEPHONE:
(650) 993-4018
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
07/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Irene MehtaTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/28/23, Licensing Program Analysts (LPAs) Grace Donato & Jaime Vado conducted a case management visit. LPAs met Designated Responsible person Irene Mehta and explained the purpose of the visit.

On 4/30/23, the department received a letter from the Licensee about their intent of selling the property and the prospective buyer will be submitting RCFE application. Licensee also stated that they will continue to operate the facility and will be working closely with the prospective applicant.

On 7/20/23 and 7/21, LPA followed up with Licensees, Flordeliza & Joey Lau, about their plans of closing the facility. Licensee Flor stated that they already sold the property in May 2023. Licensee stated that they have a lease agreement with the new property owner effective May 10, 2023.

The designated new administrator has been working with the facility effective 5/10/2023. The designee also who also happens to be the new property owner and is not associated to the facility. Licensee stated she has notified the department about the new designee by submitting LIC 308 but did not inform that they had sold the property. The Licensee stated that since they have sold the property, they haven’t been in the facility.

LPA informed the Licensee that they are still responsible to the operation of the facility. Effective 7/21, Licensee agreed and understood that they will oversee the operation of the facility until the applicant obtains his/her RCFE license.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DOUBLE HAPPINESS CARE HOME
FACILITY NUMBER: 415600735
VISIT DATE: 07/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA also reached to the property owner who confirmed control of property and is operating the facility. The new property owner has submitted his/her RCFE application to Centralized Application Bureau on 7/26/2023.

LPA also discussed with licensee and new property owner/RCFE applicant about unlicensed operation, fingerprint clearance and association, staff training, notice of closure to CCLD and responsible parties of residents.

LPA suggested that if Licensee decides to designate the new applicant to be their co-administrator, they should adhere to the Title 22 Regulations, 87405 Administrator - Qualifications and Duties.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/28/2023 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DOUBLE HAPPINESS CARE HOME
FACILITY NUMBER: 415600735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87405(b)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
This requirement is not met as evidenced by the facility licensee/administrator ceased and relinquished the operation of the facility when the facility property was sold to the new owner who doesn’t have a valid license to operate the facility which possess an immediate health, safety, or personal rights risk to persons in care.
1
2
3
4
5
6
7
Licensee stated they will submit a plan to how the licensee/administrator operate the facility. Licensee also confirmed understanding of their responsibilities and duties until a new license is approved.
Type A
07/29/2023
Section Cited
CCR
87405(d)(2)(3)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
(3) Ability to maintain or supervise the maintenance of financial and other records.
1
2
3
4
5
6
7
Licensee to submit a plan of action to update all documents for facility and personnel records.
8
9
10
11
12
13
14
This requirement is not met as evidenced by the licensee/administrator did not inform licensing of the selling of the property, designation of a new administrator, submission of fingerprint association of a new employee and new employee does not have personnel records which possess an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/28/2023 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DOUBLE HAPPINESS CARE HOME
FACILITY NUMBER: 415600735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87109(b)

1
2
3
4
5
6
7
87109 Transferability of License
(b) The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer, as specified in Health and Safety Code Section 1569.191.
1
2
3
4
5
6
7
Licensee/Administrator stated that they agreed and understood that Licensee should still be running facility up until the new owner is able to get their own License.

8
9
10
11
12
13
14
This requirement is not met as evidenced by the licensee did not notify licensing agency and residents and their responsible parties of the selling of property as of May 10, 2023 and change of ownership which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
07/29/2023
Section Cited
CCR87355(e)(2)

1
2
3
4
5
6
7
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
1
2
3
4
5
6
7
Licensee will send a written plan to ensure all staff are associated to the facility to LPA Donato by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by Licensee did not comply with the section cited above for staff (S1) working in the facility without fingerprint clearance or is not associated in the facility which poses an immediate health, safety, and personal rights risk to persons 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4