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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801563
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:49:56 PM


Document Has Been Signed on 05/18/2023 04:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:HAPPY HOME CAREFACILITY NUMBER:
565801563
ADMINISTRATOR:KAREN ROSALESFACILITY TYPE:
740
ADDRESS:179 NORTHAM AVE.TELEPHONE:
(818) 219-5998
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY:6CENSUS: 5DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Karina AntigTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two staff and five residents present. The LPA spoke with the Administrator, Karina Antig over the phone and the reason for the visit was explained. The Administrator arrived at the facility at 2:40 p.m. Entrance interview conducted.

At 1:33 p.m. the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 1:42 p.m. Knives are stored in a locked drawer next to the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:45 p.m., the hot water temperature was measured in the kitchen at 114.6 degrees Fahrenheit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed infectious disease case. The facility’s policies and procedures as it pertains to infection control are adequate.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. The laundry room is in the garage locked and inaccessible. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. There is one (1) additional refrigerator and one (1) freezer in the garage with perishable items in good condition. Facility has an adequate amount of emergency food and emergency water.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563
VISIT DATE: 05/18/2023
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Report Continued from LIC 809C...

There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There were no bodies of water noted.

COMMON AREAS: Living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguisher was observed and non-complaint as it was last serviced on 05/10/2022. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated resident rooms and one staff bedroom. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in the common hallway restroom at 110.8 degrees Fahrenheit at 1:38 p.m.

RECORDS: Records review began at 1:58 p.m.; five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. During the resident file review, it was revealed that on 01/23/2020, Resident #1 (R1) was admitted to the facility. On the Physician’s Report, dated 05/21/2021, it lists R1 as needing maximum assist and as having no capacity for self-care which is a prohibited health condition. Administrator stated R1 was on hospice until one (1) ago, when R1 was discharged from all hospice services. The licensee did not submit an exception request to retain a resident with a prohibited health condition.



Report Continued on LIC 809C...
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563
VISIT DATE: 05/18/2023
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Report Continued from LIC 809C...

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Out of the three (3) files reviewed, all files were complete. The LPA also audited the current Administrator’s file, and it was in order. The last earthquake drill took place on 04/20/2023.

MEDICATIONS: Medications review began at 3:55 p.m. The medications are centrally stored and locked in a cabinet adjacent to the living room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

During today’s visit, the LPA obtained copies of the following: Staff Roster/Schedule, Resident Roster, Emergency Disaster Plan, and a copy of Current Liability Insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/18/2023 04:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(5)
Persons who require health services for or have a health condition…shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee retained R1 who had no capacity for self-care and no record of an exception is on file, which poses an immediate health and safety risk to residents in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator will submit memo of understanding that you have read and will comply with Title 22 Regulation 87615 Prohibited Health Conditions and 87616 Exceptions for Health Conditions and submit to CCL by 5/22/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/18/2023 04:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as fire extinguisher was noted with a purchased date on 05/10/2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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The Administrator had a new fire extinguisher purchased at the time of visit.
POC has been met.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5