565801764-12-10-2022-29-AS-MARO-CLYPJV-20221210102211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801764
Report Date: 12/10/2022
Date Signed: 12/10/2022 10:22:53 AM

Document Has Been Signed on 12/10/2022 10:22 AM - 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 CARE II		FACILITY NUMBER:	565801764
ADMINISTRATOR:	MICHAEL ROSALES		FACILITY TYPE:	740
ADDRESS:	1273 SHEFFIELD PLACE		TELEPHONE:	(805) 371-7801
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	12/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Karina Antig		TIME COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on 01/27/2022. Upon arrival, the LPA was scanned and greeted at the door by Staff. The Administrator, Karina Antig arrived shortly after and the reason for the visit was explained. Entrance interview.

During today’s inspection, the LPA toured the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The LPA observed a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. All knives and sharps are kept locked in a cabinet inaccessible to residents in care. Medication and resident files were observed in a locked filing cabinet adjacent to the kitchen. BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with adequate lighting. RESTROOMS: There are two (2) resident restrooms. Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. Restrooms were measured for hot water; hot water in hallway restroom measured at 106 degrees Fahrenheit and Master Restroom measured at 105.8 degrees Fahrenheit. …Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

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 II	FACILITY NUMBER: 565801764
	VISIT DATE: 12/10/2022

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…Report Continued from LIC 809...

GARAGE AND BACKYARD: The garage is locked and inaccessible to residents. There are two (2) additional refrigerators in the garage with additional food. The LPA observed a sufficient supply of emergency water and food. 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. No bodies of water observed during time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed one (1) resident in the dining room reading the newspaper at the time of visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. Staff were observed wearing face masks during time of the visit. No identified staffing concerns.

Exit interview conducted. No deficiencies issued. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

LIC809 (FAS) - (06/04)

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