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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610100
Report Date: 01/12/2021
Date Signed: 03/09/2023 03:30:24 PM

Document Has Been Signed on 03/09/2023 03:30 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAPPY PLACE ELDER CAREFACILITY NUMBER:
197610100
ADMINISTRATOR:JAVIER, HERMAN B.FACILITY TYPE:
740
ADDRESS:23609 DAISETTA DRIVETELEPHONE:
(661) 505-7600
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 2DATE:
01/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Herman Javier - administratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an announced virtual Pre Licensing tele visit to this facility and met with applicant Herman Javier . The applicant is "HP Javier LLC". Fire Clearance dated 11/09/2020 was received for six (6) non-ambulatory residents.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

The facility is a one (1) storey building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen observed to be fully charged and was last bought on 10/28/2020. Carbon Monoxide detectors were observed in hallways. Both fire alarm and carbon monoxide detectors were tested and observed to be operational, the facility is equipped with fire sprinklers. Hot water was tested in the common bathrooms and measured at a range of 115.1 °F to 118.4°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are six (6) resident bedrooms, all private. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records is stored in a locked cabinet near the kitchen area. Medications are also stored in the same locked cabinet with the records. The first aid kit is readily available. There are three (3) bathrooms in the facility. One (1) bathroom is designated for staff use only and the common bathroom has non-skid mat and appropriate grab bars installed.

(continued on LIC 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2021
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 2
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100
VISIT DATE: 01/12/2021
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(continued from LIC 809)

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the locked garage. The laundry area is located in the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached and was observed to be locked. The swimming pool is appropriately fenced and was observed to be locked.

Component III was conducted to the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

A telephonic exit interview was conducted with Licensee Representative Herman Javier and a hard copy was provided via email for signature.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
LIC809 (FAS) - (06/04)
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