567609809-11-21-2023-29-AS-ECAS-CXSLW5-20231121080632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609809
Report Date: 11/06/2023
Date Signed: 11/21/2023 08:07:34 AM

Document Has Been Signed on 11/21/2023 08:07 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 3		FACILITY NUMBER:	567609809
ADMINISTRATOR:	ROSALES, KAREN		FACILITY TYPE:	740
ADDRESS:	191 EAST GAINSBOROUGH ROAD		TELEPHONE:	(805) 370-0214
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Karina Antig		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there was one staff and four residents present LPA explained the reason for the visit. The Administrator arrived shortly thereafter and explained the reason for the visit.

At 12:00 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 12:00 p.m. Knives are stored in a locked medication cabinet in the kitchen next to the garage entrance door. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:07p.m. the LPA observed expired milk gallons dated 10/19/2023. At 12:02 p.m., the hot water temperature was measured in the kitchen at 108.1 degrees Fahrenheit.

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

There is patio furniture including a table, umbrella, 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. There is a screen fireplace in the living room. The facility maintained a comfortable temperature of 73 degrees F. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguisher was observed and complaint as it was last purchased on 05/18/2023. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space.

Continued on LIC 802-C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 3	FACILITY NUMBER: 567609809
	VISIT DATE: 11/06/2023

NARRATIVE

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MEDICATIONS: Medications review began at 3:10 p.m. The medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. Administrator was reminded to ensure that log is maintained with the file when delivered by the pharmacy.

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.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2023 08:07 AM - 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 3	FACILITY NUMBER: 567609809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 files for each employee are not kept at the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Administrator agreed to the following: 1. Keep copies of all staff files and adminsitraor at current facility. Provide proof to CCL no later than 11/17/23.

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 a health assesment was not completed for S2 which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Adminsitrator agreed to the following: 1. Ensure that S1 has completed Health Assesment on file completed by a physician. Provide proof to CCL no later than POC 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2023 08:07 AM - 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 3	FACILITY NUMBER: 567609809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 in as there was no record of TB test for R1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	The adminsitrator agreed to the following: 1. Ensure that R1 completes TB testing and provide prrof of results to CCL no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

Page: 4 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 3	FACILITY NUMBER: 567609809
	VISIT DATE: 11/06/2023

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BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are five designated resident rooms and one staff bedroom. There was a linen closet in the laundry room 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 108.1 degrees Fahrenheit at 1:50 p.m.

RECORDS: Records review began at 2:00 p.m.; four (4) 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 10/25/2022, Resident #1 (R1) was admitted to the facility. On the Physician’s Report, dated 11/9/2022 and 10/4/2023, did not record evidence of a Tuberculosis (TB) test, further file review did not reveal any records with TB test results. Administrator stated R1 was brought to the facility by a court appointed conservator and would follow up on obtaining results.

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 two (2) files reviewed, files were incomplete as training records for Staff #1, Staff #2 (S1, S2) were not located and health assessment for Staff #2 (S2) was not completed by a physician. The administrator indicated they will have all the necessary records completed. The last earthquake drill took place on 09/23/2023.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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