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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801563
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:31:22 PM


Document Has Been Signed on 06/04/2024 03:31 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: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karina AntigTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two staff and four residents present. The Assistant Administrator Karina Antig was contacted over the phone and arrived shortly after the visit began. Entrance interview conducted.

At 11:15AM, the LPA, along with Assistant Administrator 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. The following was observed:

LPA noted the facility to be under construction currently. Notification was sent to the Regional Office (RO) on 05/14/2024 indicating 1 bathroom would be renovated and kitchen flooring replaced. Notification also indicated no major construction required and that the scheduled time frame was 05/13/2024 to 05/25/2024. No extension or change of scope of work was received at the RO as of today's date. LPA discussed with Assistant Administrator sending an updated notification letter, as well as ensuring all required building permits are obtained.

BEDROOMS: Typically, there are 4 (four) designated resident rooms and 1 (one) staff room inside the locked garage area, as well as an upstairs area solely dedicated to staff use. At this time, 3 (three) resident rooms are being utilized for resident sleeping use and a vacant resident room is being utilized as a shared common space. LPA observed the 3 (three) resident rooms to contain appropriate linens and furnishings. However, exit doors in all 3 (three) rooms were blocked with storage items, and at least 1 (one) of the doors was observed to be dead bolted shut at the time of the visit.

RESTROOMS: The facility contains 2 (two) shared resident restrooms and 1 (one) staff restroom upstairs. The bathrooms were sufficiently stocked with supplies and paper towels. 1 (one) resident restroom was locked and under construction. The hot water temperature was measured in the common hallway restroom at 129.4 degrees Fahrenheit at 11:28AM. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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: 06/04/2024
NARRATIVE
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KITCHEN: The kitchen area was observed to be covered in plastic and currently under construction. All appliances have been removed and/or relocated. Beginning at 11:43AM, LPA observed the facility refrigerator to be in the dining room, and containing multiple expired foods, including but not limited to: 4 18-packs of eggs with a use by date of 05/24/2024, Best Foods Mayonnaise with a best before date of 03/10/2024, Tree Top Applesauce with a best buy date of 07/25/2023, grapes and vegetable medley that were observed browned. Additionally, LPA noted multiple plastic storage containers containing leftover foods, which were not labeled nor dated. Assistant Administrator stated that due to the kitchen construction, they are currently utilizing an off-site kitchen to prepare dinner. Lunch and breakfast are prepared by staff either in the facility side yard or in the dining room using small kitchen appliances only.

COMMON AREAS: Due to the construction, the living room and dining room are being used as storage areas. The common living room has been relocated to a vacant resident room. 2 (two) fire extinguishers were observed to be fully charged and last serviced 05/14/2024. Front door exit contains a latch at the bottom, and all other remaining common area exits were observed to be blocked and/or locked at the time of the visit. The LPA observed required postings throughout the common space.

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. Facility has an adequate amount of emergency food and emergency water. Outdoor area was observed to be used as storage and preparation for the construction, so was unable to be properly assessed for compliance. Passageway to the exit gate was observed to be blocked by a table containing small kitchen appliances.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Not reviewed during today's visit.

RECORDS/MEDICATIONS: LPA reviewed 2 (two) resident files during today's visit. LPA observed both residents to be on hospice, however the facility's approved hospice waiver is for 1 (one) hospice resident. Remaining files will be reviewed during the annual continuation visit. Medications were observed to be stored locked; medications were not reviewed today.

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. A $500 civil penalty was assessed. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of today's report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/04/2024 03:31 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 smoke detectors located in the main hallway leading to resident rooms had been removed during facility painting which occurred mid-May and had yet to be reinstalled, as well as at least 1 (one) sprinkler had paint on it and the front door latches into the floor, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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During today's visit, facility maintenance person reinstalled the smoke detectors. Smoke detectors were tested during the visit and functioned. Assistant Administrator indicated they will remove additional sprinkler covers to ensure no other sprinklers were accidently painted. Assistant Administrator will ensure all damaged sprinklers are replaced and the front door latch is removed and will send proof to CCL by POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the 1 (one) useable handwashing sink for residents was observed with a water temperature of 129.4 degrees Fahrenheit, which poses an immediate safety risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Assistant Administrator had maintenance person lower the hot water heater during today's visit. Assistant Administrator will test the water temperature at various times of the day over the course of a 7-day period, complete a log of these recorded temperatures and will submit the temperature log to CCL by POC due date.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/04/2024 03:31 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 2 (two) residents were observed to be admitted to hospice care, however, the facility only has an approved hospice waiver for 1 (one) resident, which poses an immediate health and personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Assistant Administrator intends to submit a request to increase the total hospice waiver. This increase request will be submitted to CCL by POC due date. Alternatively, proof of discharge from hospice care for one of the residents or an exception request may be submitted to CCL by POC due date if the licensee so chooses in lieu of the request to increase the number of residents approved on the hospice care waiver.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 dining room exit, living room exit, as well as the exits from all 4 (four) of 4 (four) resident rooms were observed to be blocked and/or locked, as well as the exit path leading to the exit gate was observed to be narrowed by placing a table in the walkway and unable for a wheelchair or walker to pass through, which poses an immediate safety and personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Assistant Administrator agreed to remove all items blocking doorways, and to unlock all resident bedroom outside exit doors and to provide proof to CCL by POC due date.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/04/2024 03:31 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 multiple expired foods were observed in the facility refrigerator, including mayonnaise, eggs, applesauce, grapes, and vegetables and additional leftover items were stored covered but not labeled, which poses a potential health risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Assistant Administrator agreed to audit the remaining items in the refrigerator and ensure no additional items are beyond their expiration dates and agreed to throw away any unlabeled items and ensure all other items are labeled in compliance. Assistant Administrator will send proof to CCL of completed audit and labeled items by POC due date.
Section Cited
Postural Supports
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5