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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610100
Report Date: 12/07/2021
Date Signed: 12/27/2021 10:09:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20211109122421
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: 5DATE:
12/07/2021
UNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Herman JavierTIME COMPLETED:
05:09 PM
ALLEGATION(S):
1
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9
Staff provided resident medication without a prescription
INVESTIGATION FINDINGS:
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12
13
Licensing Program Analyst (LPA) Abeye Duguma conducted subsequent complaint visit to the facility. LPA met with the Administrator Herman Javier and explained the purpose of this visit.
It was alleged that amphetamine was found in patient's laboratory result and that someone "must've slipped it in on Wednesday or Thursday'' (11/02/2021 or 11/03/2021). During this investigation, on 11/10/2021 at 11:30am, LPA interviewed the Administrator who had prior knowledge of the issue. The Administrator tested facility staff and the results were all negative. Administrator requested re-testing of resident #1 (R1), but later learned that R1’s system was flushed, and any re-testing attempts would be futile. On 12/07/2021 at 3:30pm, LPA interviewed R1 and R1 had no knowledge of how amphetamine got in their system. On 12/07/2021 at 04:00pm, LPA interviewed other parties involved in R1’s care and supervision, and no one notice anything out of the ordinary or recognized R1 exhibiting any odd behavior. On 12/07/2021 at 4:30pm, LPA spoke with former staff, who stated that they have no idea how R1 tested positive for amphetamine and did not observe any odd behavior from staff, residents or visitors.
(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20211109122421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/07/2021
NARRATIVE
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On 11/24/2021 at 10:00am, LPA conducted a record review of medication records of all residents, including R1, and noted that none of the medications consumed by the residents contained amphetamine.

Based on interviews and record reviews, there is not enough supporting information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2