565801764-1-19-2024-29-AS-ECOZ-CZMTYX-20240119140928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801764
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:10:35 PM

Document Has Been Signed on 01/19/2024 02:10 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
WOODLAND HILLS N.ASC, 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:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karina Roales Antig-Co Administrator		TIME COMPLETED:	02:15 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	At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Karina Rosales Antig arrived shortly. At 9:40 a.m. the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms, one (1) staff room, and two (2) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and last purchased on 05/18/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. At 9:41 a.m. the LPA observed two knives in the unlocked dish washer machine. At 9:43 a.m. the LPA observed Robitussin cough+sore throat medication, Greri Tussin DM medication, and Nystatin 100,000 unit/ml medication in the kitchen refrigerator accessible to residents in care. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. At 10:01 a.m. the LPA did not observed a required “No Smoking-Oxygen in use” sign in room #2 due to use of oxygen equipment. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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

Document Has Been Signed on 01/19/2024 02:10 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE II	FACILITY NUMBER: 565801764
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

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: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Intervieew and record review, the licensee did not comply with the section cited above as Per R5’s physician’s report, R5 is identified as bedridden. Per the fire clearance, the facility does not have a bedridden fire clearance at this time which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/20/2024
	Plan of Correction
1 2 3 4	The Administrator will submit LIC200, LIC850 and copy of facility sketch to CCL to request bedridden fire clearance by the end of business day 01/20/2024. This is a zero-tolerance violation, resulting in a civil penalty in the amount of $500.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA observed medication in the refrigerator, and paint, nails, and hardarware in the back yard accessible to residents iwhich poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/20/2024
	Plan of Correction
1 2 3 4	Administrator agreed to do the following: 1.remove all items and lock away by the end of day, and submitt proof to CCL. 2. Provide documentation staff training regarding regulation 87705(f)(1) to CCL by 1/20/24.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/19/2024 02:10 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE II	FACILITY NUMBER: 565801764
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 2/5 (R1, R2) did not have a pre-placement appraisal (LIC 603), or appraisal/needs and services plan (LIC625). 3/5 (R3,R4,R5) did not have a required updated annual LIC625. which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	The administrator agrees to update all appraisals/needs and services plans for all residents and inform CCL when this has been completed, no later than POC due date.

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there was no-smoking sign in room#2 where there is use of oxygen equipment and Administrator advised the LPA the fire dept. has not been notified in writting there is Oxygen in use which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/22/2024
	Plan of Correction
1 2 3 4	Administrator placed sign during the visit and will notify fire dept there is Oxygen in use at the facility 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE II	FACILITY NUMBER: 565801764
	VISIT DATE: 01/19/2024

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

Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 10:14 a.m. water temperature in resident’s restroom was measured at 116.3 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. There were no obstructions and/or tripping hazards throughout the facility. The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. The LPA observed paint buckets, nails, and equipment in the backyard. Upon observation the administrator stated maintenance will be picking up all items today.
Record Review: At 11:13 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of five (5) resident files. The following was observed: Two out five residents (R1, R2) did not have a pre-placement appraisal (LIC 603), or appraisal/needs and services plan (LIC625). Three out of five Residents (R3,R4,R5) did not have a required annually updated LIC625. At 10:20 a.m., the LPA observed R5 residing in room five (5), which is not an identified bedridden room. Per R5’s physician’s report, R5 is identified as bedridden. Per the fire clearance, the facility does not have a bedridden fire clearance at this time. Administrator could not verify if they a bedridden fire clearance. An immediate civil penalty of $500 is assessed, due to a violation of the fire clearance. The LPA obtained a Client Roster and Staff Roster.

Interviews: The LPA conducted two (2) resident Interviews. No immediate concerns were voiced.

Due to time constraints the LPA will return at a later date to complete the annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Karina Rosales Antig.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4